Tanveer Singh Kundra

To evaluate dexmedetomidine as an additive to propofol for sedation for elective cardioversion in a cardiac intensive care unit: A double-blind randomized controlled trial

Introduction: Propofol may lead to patient recall and discomfort when used for sedation in elective cardioversion. The aim of the present study was to evaluate dexmedetomidine as an additive to propofol for sedation in elective cardioversion. Materials and Methods: A total of 500 patients undergoing elective cardioversion were randomized into Group 1 (n = 250) and Group 2 (n = 250) on the basis of computer-generated randomization table. Patients in Group 1 were given dexmedetomidine (1 mcg/kg) over 10 min before giving propofol (1 mg/kg), while patients in Group 2 were given only propofol (1 mg/kg). One or two additional doses of 0.5 mg/kg propofol were given if modified Ramsay Sedation Score (mRSS) was <5. Number of patients requiring additional doses were noted. Any hemodynamic or respiratory complication along with the mean time to recovery (mRSS = 1) was recorded. Patient recall, patient discomfort, and further requirement of cardioversion in the next 24 h were also noted. Results: About 10% patients in Group 1 and 64% patients in Group 2 required the first additional dose of propofol. While no patient in Group 1 required second dose, 16% patients in Group 2 required second dose of propofol. The mean time to recovery in Group 1 was 8.36 ± 3.08 min and 8.22 ± 2.38 min in Group 2 (P = 0.569). Sixty-seven patients (26.8%) in Group 1 and 129 patients (51.6%) in Group 2 reported remembering something (P < 0.0001), i.e., recall. Thirty-five patients (14%) in Group 1 and 79 patients (31.6%) in Group 2 reported dreaming during the procedure (P < 0.0001). Visual analog scale score was higher in Group 1 as compared to Group 2. Six patients in Group 1 and 24 patients in Group 2 had a requirement of repeat cardioversion in 24-h follow-up (P = 0.001). Conclusions: Dexmedetomidine is a useful adjunct to propofol for elective cardioversion.

Effect of Dexmedetomidine on Normal Coronary Vessel Diameter

Dexmedetomidine is a selective alpha2 agonist, which is widely used for conscious sedation in ICU patients. It is being increasingly used to provide conscious sedation in out-of-theatre procedures like CT scan, MRI, endoscopies and catheterization (cath) procedures. There is limited data till date regarding the effect of dexmedetomidine on coronary vessel diameter. The aim of this prospective observational study was to observe the effect of dexmedetomidine on normal coronary vessel diameter. Fifty patients who had come for elective coronary angiography in the cath lab were enrolled in the study. After taking the first shot of the coronary angiogram and confirming that the right coronary artery (RCA) is normal, dexmedetomidine was administered in a dose of 1 µg/kg intravenously over 15 min. Immediately after that, another shot was taken to check the diameter of RCA. Paired Students t test was used to analyze the data. The mean diameter of RCA before giving dexmedetomidine was 2.7634 ± 0.3189 mm. The mean diameter decreased significantly to 2.6296 ± 0.3379 mm after administration of dexmedetomidine (p value <0.0001). Thus, dexmedetomidine decreases the coronary vessel diameter.

Effect of dexmedetomidine on diseased coronary vessel diameter and myocardial protection in percutaneous coronary interventional patients.

Introduction: Dexmedetomidine is an alpha-2 agonist used for conscious sedation. It has also been shown to have a myocardial protective effect in off-pump coronary artery bypass patients. The aim of the study was to assess the effect of dexmedetomidine for myocardial protection in percutaneous coronary interventional patients. Methodology: A total of 60 patients (group dexmedetomidine, n = 30 and group normal saline, n = 30) were enrolled in the study. Dexmedetomidine infusion (1 mcg/kg) over 15 min was given as a loading dose after coronary angiography in group dexmedetomidine (D) while normal saline was given in the control group (C) and later maintenance infusion was started at 0.5 mcg/kg/h in both the groups. Coronary vessel diameter was noted before (T0) and after (T1) loading dose of dexmedetomidine/saline in each group. Troponin T (Trop T) values were noted at baseline (T0), 6 h (T2), 12 h (T3) and 24 h (T4) after starting the loading dose. Hemodynamic variables (heart rate [HR] and blood pressure) were monitored at T0, T1, and at regular intervals till 2 h postprocedure. Results: Coronary vessel diameter and HR significantly decreased in group D as compared to control group (P < 0.05) whereas the decrease in Trop T at 6 h, 12 h, and 24 h were not statistically significant between the two groups. Conclusion: Dexmedetomidine decreases the coronary vessel diameter, but maintains the myocardial oxygen demand-supply ratio by decreasing the HR. The decrease in Trop T is statistically insignificant at the doses used.

Naphthalene Poisoning following Ingestion of Mothballs: A Case Report.

Naphthalene is a widely used industrial and household chemical in the form of mothballs. But it has rarely been an agent of poisoning worldwide. We describe a case of ingestional naphthalene poisoning with a good outcome after proper management. A 29-year-old girl ingested 8 mothballs, and presented two days later with haemolysis and methaemoglobinaemia. She was given intravenous methylene blue, N-acetylcysteine and ascorbic acid, besides supportive treatment. Renal replacement therapy in the form of SLED of 8 hours was done on a daily basis. She was discharged after ten days on twice a week outpatient follow-up haemodialysis.

The Effect of Inhaled Milrinone Versus Inhaled Levosimendan in Pulmonary Hypertension Patients Undergoing Mitral Valve Surgery — A Pilot Randomized Double-Blind Study

OBJECTIVE To compare the effects of inhaled milrinone and levosimendan on pulmonary and systemic hemodynamics in patients with pulmonary hypertension. DESIGN Prospective, double-blind, randomized controlled study. SETTING Tertiary care cardiac institute with 650 beds. PARTICIPANTS The study comprised 150 adult patients with pulmonary hypertension undergoing mitral valve surgery. INTERVENTIONS Patients were assigned randomly into 1 of the following 3 groups: milrinone (M), levosimendan (L), or control (C); n = 50 per group. In group M, inhaled milrinone (50 µg/kg); in group L, inhaled levosimendan (24 µg/kg); and in group C, normal saline was administered when the patient arrived in the recovery room. Pre-inhalation and post-inhalation hemodynamics (mean arterial pressure [MAP], pulse rate, and systemic vascular resistance [SVR]) were noted until 24 hours of inhalation of the drug. The change in pulmonary artery pressures (pulmonary artery systolic pressure [PASP] and mean pulmonary artery pressure [MPAP]) and the duration for which they remained decreased compared with the control group, were noted. MEASUREMENTS AND MAIN RESULTS MAP, pulse rate, and SVR were comparable in the 3 groups at various time intervals. PASP and MPAP decreased comparably after inhalation of levosimendan and milrinone. However, they reached levels near the control group values after 2.5 to 3 hours in group L and after 0.5 hours in group M. CONCLUSIONS Because inhaled levosimendan causes a decrease in PASP and MPAP without causing a decrease in SVR and MAP, the authors conclude that inhaled levosimendan is a selective pulmonary vasodilator. It is as effective as milrinone in reducing pulmonary artery pressures. In addition, it has advantage over inhaled milrinone because it is has a longer duration of action.

Dexmedetomidine for prevention of skeletal muscle ischaemia-reperfusion injury in patients with chronic limb ischaemia undergoing aortobifemoral bypass surgery: A prospective double-blind randomized controlled study

Background: Dexmedetomidine is a selective α-2 agonist used for sedation. It has also been shown to have myocardial protective effect and prevent ischemia-reperfusion injury in off-pump coronary artery bypass patients. The aim of our study was to assess the effect of dexmedetomidine for prevention of skeletal muscle ischemia-reperfusion injury in patients undergoing aortobifemoral bypass surgery. Methodology: Sixty adult patients (Group dexmedetomidine n = 30, Group normal saline n = 30) undergoing aortobifemoral bypass surgery were recruited over 3 months. Randomization was done using a computer-generated random table. The attending anesthesiologist would be blinded to whether the drug/normal saline was being administered. He would consider each unlabeled syringe as containing dexmedetomidine and calculate the volume to be infused via a syringe pump accordingly. Dexmedetomidine infusion (1 mcg/kg) over 15 minutes was given as a loading dose, followed by maintenance infusion of 0.5 mcg/kg/h till 2 h postprocedure in Group dexmedetomidine (D) while the same volume of normal saline was given in the control Group C till 2 h postprocedure. Creatine phosphokinase (CPK) values were noted at baseline (T0), 6 h (T1), 12 h (T2), and 24 h (T3) after the procedure. Hemodynamic variables (heart rate [HR] and mean blood pressure [MAP]) were recorded at T0, T1, T2, and T3. Results were analyzed using unpaired Students t-test, P < 0.05 was considered statistically significant. Results: MAP and HR significantly decreased in Group D as compared to control group (P < 0.05). However, the decrease was never <20% of the baseline. The CPK values at 6, 12, and 24 h were statistically significant between the two groups. Conclusion: Dexmedetomidine prevents skeletal muscle ischemia-reperfusion injury in patients undergoing aortobifemoral bypass surgery.

A comparative study on the efficacy of dexmedetomidine and tramadol on post-spinal anesthesia shivering

Background: Shivering is a common postanesthesia adverse event with multiple etiologies. At present tramadol is a widely used drug for the control of shivering. However, tramadol may cause a lot of nausea and vomiting. Hence, the need to find a better drug with less of side effects. The aim of this study was to compare the efficacy of dexmedetomidine and tramadol in the treatment of post-spinal anesthesia (SA) shivering as well as to compare their side-effect profile. Materials and Methods: This prospective, double-blind, randomized controlled trial was conducted in a tertiary care hospital. A total of 100 patients having shivering after SA were enrolled, out of which fifty received dexmedetomidine (Group A) and 50 received tramadol (Group B). The response rate, time to cessation of shivering and side effects (if any) was noted. All the results were analyzed using Students t-test and Chi-square test. Results: All patients who received dexmedetomidine as well as tramadol had cessation of shivering. The time to cessation of shivering was significantly less with dexmedetomidine (174.12 ± 14.366 s) than with tramadol (277.06 ± 23.374 s) (P < 0.001). The recurrence rate of shivering with dexmedetomidine was less (6%) as compared to tramadol (16%). Nausea and vomiting was found to be higher in the case of tramadol. On the other hand, dexmedetomidine caused moderate sedation (modified Ramsay sedation score = 3–4) from which the patient could be easily awoken up. Conclusion: Dexmedetomidine offers better results than tramadol with fewer side effects.

The minimum dose of dexmedetomidine required for cessation of postspinal anesthesia shivering: A prospective observational study

Background and Aims: Shivering is a common postanesthesia adverse event with multiple etiologies. Dexmedetomidine, a centrally acting alpha-2 adrenergic agonist, is known to reduce the shivering threshold. However, the minimum dose at which dexmedetomidine causes cessation of shivering is unknown. The aim of this prospective observational study was to find the minimum dosage of dexmedetomidine required for abolition of post-spinal anesthesia (SA) shivering. Material and Methods: Thirty patients having shivering after SA were enrolled, who received dexmedetomidine in the dosage of 1 mcg/kg over 10 min. The time-to-cessation of shivering and the dose of dexmedetomidine required were expressed as mean ± standard deviation. Results: The mean time-to-cessation of shivering after starting dexmedetomidine infusion was 155.88 ± 15.16 s for Grade 3 shivering and 177.71 ± 10.87 s for Grade 4 shivering. Till that time, the mean dose of dexmedetomidine which had been infused was 0.258 ± 0.024 mcg/kg in Grade 3 shivering and 0.295 ± 0.018 mcg/kg in Grade 4 shivering. Conclusion: The minimum dose of dexmedetomidine required for abolition of shivering was 0.258 ± 0.024 mcg/kg for patients with Grade 3 shivering and 0.295 ± 0.018 mcg/kg for patients with Grade 4 shivering, which is much less than the commonly administered dose.

Comparative efficacy of clonidine versus magnesium sulfate as an adjunct to lignocaine in intravenous regional anesthesia for postoperative analgesia: A prospective, randomized, double-blind study

Background and Aims: Intravenous regional anesthesia (IVRA) is a very good technique to be used in unstable patients. Various adjuvants have been added, but till date, there is no ideal adjuvant. Clonidine is one of the most widely used adjuvants in IVRA. However, it has many side effects. Hence, the search continues for a better adjuvant. The aim of the present study was to compare the efficacy of clonidine versus MgSO4 as an adjunct to lignocaine in IVRA for postoperative analgesia and to compare their side effect profile. Material and Methods: This prospective double-blind randomized controlled study was conducted in a tertiary care institute. Forty adult patients were included. Patients were assigned into two groups; Group 1 (n = 20) received 3 mg/kg of 2% lignocaine + 50% MgSO4 1.5 g diluted with normal saline to 40 ml. Group 2 (n = 20) received 3 mg/kg of 2% lignocaine + clonidine 150 μg diluted with normal saline to 40 ml. Pain score, time to first rescue analgesic (TTFA), total number of rescue analgesics required, and the side effects of the two drugs were compared for 24 h postoperatively. Results: The mean TTFA was significantly longer in Group 1 (193.9 ± 38.4 min) than in Group 2 (169.5 ± 33.3 min); P < 0.05. The mean number of rescue analgesics required was 1.6 ± 0.7 in Group 1 as compared to 2.1 ± 0.8 in Group 2 (P < 0.05). More serious side effects such as hypotension and bradycardia were noted with clonidine, although all patients experienced transient pain during intravenous injection of MgSO4. Conclusion: MgSO4 provides better postoperative analgesia as compared to clonidine when used as an adjunct to lignocaine in IVRA with fewer side effects.

Prayer sign as a marker of increased ventilatory hours, length of intensive care unit and hospital stay in patients undergoing coronary artery bypass grafting surgery

Context: Various predictors have been used to predict diabetic patients who are likely to have increased ventilatory hours and an increased length of stay (LOS) in the Intensive Care Unit (ICU) as well as in the hospital after undergoing coronary artery bypass grafting (CABG) surgery, for example, glycosylated hemoglobin (HbA1c). The authors propose a simple bed-side test, i.e., the prayer sign to predict increased ventilatory hours and increased length of ICU and hospital stay. Aims: The aim of the present study was to assess whether any association exists between a positive prayer sign and increased ventilatory hours, length of ICU and hospital stay after CABG surgery in diabetic patients. Settings and Design: This prospective observational study was conducted in a 650-bedded tertiary cardiac center. Subjects and Methods: A total of 501 diabetic patients were recruited in the study over a period of 1 year. Group P consisted of 121 patients with prayer sign positive, whereas Group N consisted of 380 patients with prayer sign negative. HbA1c levels, ventilatory hours, LOS in the postoperative ICU and hospital were compared. Statistical Analysis Used: Unpaired Student′s t-test was used to compare the data. Results: The mean HbA1c levels in Group P were 8.01 ± 2.28% as compared to 6.52 ± 2.46% in Group N (P < 0.0001). The mean ventilatory hours in Group P were 9.52 ± 6.46 h, and in Group N were 7.42 ± 8.01 h (P = 0.013). Whereas, the mean length of ICU stay and hospital stay in Group P was 156.42 ± 32.66 h (6.51 ± 1.36 days) and 197.36 ± 32.46 h (8.22 ± 1.35 days), respectively, it was 121.12 ± 29.48 h (5.04 ± 1.22 days) and 178.52 ± 28.52 h (7.43 ± 1.18 days) in Group N (P < 0.0001). Conclusions: A positive prayer sign is a useful bedside test for predicting increased ventilatory hours and increased length of ICU and hospital stay after CABG surgery.