Tej K Kaul

Preemptive analgesia with ketamine for laparoscopic cholecystectomy

Background: The aim of preemptive analgesia is to reduce central sensitization that arises from noxious inputs across the entire perioperative period. N-methyl d-aspartate receptor antagonists have the potential for attenuating central sensitization and preventing central neuroplasticity. Materials and Methods: Patients undergoing laparoscopic cholecystectomy were randomized into four groups of 20 patients each, who were administered the study drug intravenously 30 min before incision. Groups A, B, and C received ketamine in a dose of 1.00, 0.75 and 0.50 mg/kg, respectively, whereas group D received isotonic saline. Anesthetic and surgical techniques were standardized. Postoperatively, the degree of pain at rest, movement, and deep breathing using visual analogue scale, time of request for first analgesic, total opioid consumption, and postoperative nausea and vomiting were recorded in postanesthesia care unit for 24 h. Results: Pain scores were highest in Group D at 0 h. Groups A, B, and C had significantly decreased postoperative pain scores at 0, 0.5, 3, 4, 5, 6, and 12 h. Postoperative analgesic consumption was significantly less in groups A, B, and C as compared with group D. There was no significant difference in the pain scores among groups A, B, and C. Group A had a significantly higher heart rate and blood pressure than groups B and C at 0 and 0.5 h along with 10% incidence of hallucinations. Conclusion: Preemptive ketamine has a definitive role in reducing postoperative pain and analgesic requirement in patients undergoing laparoscopic cholecystectomy. The lower dose of 0.5 mg/kg being devoid of any adverse effects and hemodynamic changes is an optimal dose for preemptive analgesia in patients undergoing laparoscopic cholecystectomy.

Efficacy of intravenous fluid warming for maintenance of core temperature during lower segment cesarean section under spinal anesthesia

Introduction: Maintenance of body temperature of obstetrical patients undergoing cesarean section is complicated by a variety of factors including heat loss to atmosphere, infusion of fluids at room temperature, disruption of thermoregulatory mechanisms by epidural or spinal anesthesia and redistribution hypothermia. Infusion of warm fluids is an important method of heat conservation. Hence, we evaluated the efficacy of intravenous fluid warming in preventing hypothermia by observing the change in core temperature with intravenous fluids at room temperature (22°C and 39°C) in patients undergoing lower segment cesarean section under spinal anesthesia. Materials and Methods: Sixty-four patients belonging to ASA grade I and II were randomly allocated to either of the two groups. Group I received intravenous fluids at room temperature (22°C) and group II received intravenous fluids via fluid warmer (39°C). Core temperature was recorded at every 1 min for the first 5 min, followed by 10 min till the end of surgery using a tympanic thermometer. Results: The mean decrease in core temperature in group I was -2.184 ± 0.413 and -1.934 ± 0.439 in group II. The comparison of group I and II showed a statistically significant difference in mean core temperatures at times 5, 50, 60, 70, 80 and 90 min and immediately on arrival in the recovery room. A lower incidence of shivering was seen in group II patients, but the difference in the two groups was not statistically significant. Conclusion: Infusion of warm intravenous fluids resulted in a lesser degree of fall in core temperature, thereby providing a significant temperature advantage; however, this did not translate to prevention of postoperative shivering.

Use of vegetarian propofol in Jain community of India

We were interested to read the letter entitled Consent for anaesthesia (Chapman & Wolff. Anaesthesia 2002; 57: 710) as we grapple with the problem of what and how much to tell patients about their anaesthetic. As a follow up to the audit of Drs Chapman and Wolff, we asked a group of 100 patients the same questions before and then after surgery and whether, in retrospect, they felt they had received an appropriate amount of information. Before surgery, the patients were asked to indicate their preference as follows: 1. I would like to be given a full and detailed explanation of the anaesthetic, any possible alternatives, together with all the risks and benefits of each technique. 2. I would like a simple description of the anaesthetic together with an explanation of the main risks and benefits. 3. I expect that my best interests will be followed and I would like to be told as little as possible about the anaesthetic. The postoperative questions were: 1. Did you receive an appropriate amount of information about the anaesthetic prior to the operation? 2. If no, would you have liked less information or more information either written or verbal? We also collected basic demographic data of age, gender and occupation. Of the 100 patients presenting for general or urological surgery, 88 were elective and 12 urgent. The gender ratio was male 44, female 56, and the age distribution is shown in Table 1. The results of the audit are summarised in Tables 2 and 3: When broken down by gender, there was little difference in the amount of information desired or received. When analysed by age, the majority in each age group wanted Level 2 information except in the over 80s who preferred Level 3 (minimal) information. There were more in the 40–59 age group who wanted Level 1 than in other age groups, but a consistent one-third in each group between 20 and 80 years only wanted Level 3. No trends emerged with regard to occupational group. In contrast to the audit by Chapman and Wolff, the majority of our patients wanted Level 2 information, i.e. a simple explanation of the procedure and main risks and benefits (which perhaps reflects our more elderly population). Patients wanting Level 1 information were in a minority regardless of age. Nevertheless, it was gratifying that 83% of those wanting Level 1 and over 90% of those wanting partial or minimal information were satisfied with what they were told. At present, all our patients get a pamphlet about coming to theatre but not one purely dedicated to anaesthesia, although we are planning to introduce new ones based on the Royal College of Anaesthetists published booklets. However, this audit reminds us that about a third of our patients only want minimal information anyway and are happy with what they are getting. More detailed written information probably should be offered

Mapleson's breathing systems

Mapleson breathing systems are used for delivering oxygen and anaesthetic agents and to eliminate carbon dioxide during anaesthesia. They consist of different components: Fresh gas flow, reservoir bag, breathing tubes, expiratory valve, and patient connection. There are five basic types of Mapleson system: A, B, C, D and E depending upon the different arrangements of these components. Mapleson F was added later. For adults, Mapleson A is the circuit of choice for spontaneous respiration where as Mapleson D and its Bains modifications are best available circuits for controlled ventilation. For neonates and paediatric patients Mapleson E and F (Jackson Rees modification) are the best circuits. In this review article, we will discuss the structure of the circuits and functional analysis of various types of Mapleson systems and their advantages and disadvantages.

A comparative study on postoperative pain relief in laparoscopic cholecystectomy: Intraperitoneal bupivacaine versus combination of bupivacaine and buprenorphine

Context: To assess the analgesic efficacy of the combination of bupivacaine and buprenorphine in alleviating postoperative pain following laparoscopic cholecystectomy. Aims: Laparoscopic cholecystectomy is comparatively advantageous as it offers less pain in the postoperative period and requires a shorter hospital stay. There are only a few studies performed to evaluate the analgesic efficacy of intraperitoneal instillation of buprenorphine and bupivacaine during laparoscopic cholecystectomy. Settings and Design: The present research is a randomized, double-blind controlled study conducted in the Department of Anaesthesiology, Dayanand Medical College and Hospital Ludhiana, Punjab after formal ethical approval from Hospitals Ethics Committee. Subjects and Methods: This study analyzed 90 adults admitted for elective laparoscopic cholecystectomy. After the procedure, subjects were divided into three equal groups to conduct the study. Three Groups A, B, and C had intraperitoneal instillation of the 25 ml of physiological saline (0.9% normal saline), 0.25% of bupivacaine, 0.25% bupivacaine, and 0.3 mg buprenorphine, respectively. Necessary vitals were monitored and recorded. Visual analog scale (VAS) and verbal rating scale (VRS) scores were recorded and analyzed systematically. Statistical Analysis Used: All observations were analyzed using analysis of variance and Students t-test. Results: The mean pain scores were highest in Group A compared to Group B and Group C. Mean VAS and VRS scores were highest in Group C comparatively and lowest in Group A. Conclusion: Combination of buprenorphine and bupivacaine intraperitoneally is comparatively more effective in relieving postoperative pain in comparison to intraperitoneal instillation of bupivacaine alone for postoperative pain management after laparoscopic cholecystectomy.

Effect of intravenous esmolol on analgesic requirements in laparoscopic cholecystectomy

Background and Aims: Perioperative beta blockers are also being advocated for modulation of acute pain and reduction of intraoperative anesthetic requirements. This study evaluated the effect of perioperative use of esmolol, an ultra short acting beta blocker, on anesthesia and modulation of post operative pain in patients of laproscopic cholecystectomy. Material and Methods: Sixty adult ASA I & II grade patients of either sex, scheduled for laparoscopic cholecystectomy under general anesthesia, were enrolled in the study. The patients were randomly allocated to one of the two groups E or C according to computer generated numbers. Group E- Patients who received loading dose of injection esmolol 0.5 mg/kg in 30 ml isotonic saline, before induction of anesthesia, followed by an IV infusion of esmolol 0.05 μg/kg/min till the completion of surgery and Group C- Patients who received 30 ml of isotonic saline as loading dose and continuous infusion of isotonic saline at the same rate as the esmolol group till the completion of surgery. Results: The baseline MAP at 0 minute was almost similar in both the groups. At 8th minute (time of intubation), MAP increased significantly in group C as compared to group E and remained higher than group E till the end of procedure. Intraoperatively, 16.67% of patients in group C showed somatic signs as compared to none in group E. The difference was statistically significant. 73.33% of patients in group C required additional doses of Inj. Fentanyl as compared to 6.67% in group E. Conclusions: We conclude that intravenous esmolol influences the analgesic requirements both intraoperatively as well as postoperatively by modulation of the sympathetic component of the pain i.e. heart rate and blood pressure.

Prophylaxis with oral clonidine prevents perioperative shivering in patients undergoing transurethral resection of prostate under subarachnoid blockade

BACKGROUND: We investigated the efficacy of oral clonidine 150 mg to prevent perioperative shivering in patients undergoing transurethral resection of prostate under subarachnoid block. Geriatric patients who undergo transurethral resection of prostate are prone to perioperative shivering during spinal anesthesia. Use of prophylactic oral clonidine, which is known to reduce shivering, could lead to decrease in the morbidity and mortality of such patients. MATERIALS AND METHODS: In this prospective double blinded placebo-controlled study, 80 patients scheduled for transurethral resection of prostate surgery under subarachnoid block were randomized into two groups. Group I (n=40) received oral clonidine 150 mg, while Group II (n=40) were given placebo tablet. After achieving subarachnoid block, the incidence, severity and duration of shivering was recorded and compared in both the groups. The body temperature (axillary, forehead and tympanic membrane), hemodynamic parameters and arterial saturation were recorded at regular intervals. RESULTS: Incidence of shivering was significantly less in patients who were given oral clonidine when compared with that of the placebo group (5 vs. 40% respectively; P value of <0.01). Clonidine did not lead to any collateral clinically significant side effects. CONCLUSION: We conclude that as a prophylaxis oral clonidine 150 mg is effective in reducing the incidence, severity and duration of perioperative shivering in patients undergoing transurethral resection of prostate surgery under spinal anesthesia.

Effect of repeat bolus dose of propofol on succinylcholine-induced fasciculations and myalgia

Background: Succinylcholine-induced fasciculations and myalgia are common and troublesome for the patients. A few studies have used propofol to minimize succinylcholine-induced fasciculations and myalgia, but none of these have used a repeat bolus dose. Materials and Methods: A prospective, randomized, double blind study was designed to assess the effect of a repeat bolus dose of propofol on succinylcholine-induced fasciculations and myalgia. Ninety adult patients scheduled for elective surgery under general anesthesia were selected by computer-generated random numbers and allocated to one of the three equal groups randomly. Anesthesia was induced with intravenous injection of propofol 2 mg/kg, followed by administration of succinylcholine 1.5 mg/kg. Immediately after the injection of succinylcholine a repeat bolus of propofol was given as per group. Group I: No repeat dose of propofol; Group II: Repeat propofol bolus of 0.5 mg/kg body weight; Group III: Repeat propofol bolus of 1.0 mg/kg body weight. Muscle fasciculations were observed and graded as nil (0), mild (1), moderate (2), or severe (3). Postoperative myalgia were assessed every 6 hourly for 24 h and then at 48 h and graded as nil (I), mild (II), moderate (III), or severe (IV). Results: The overall incidence of muscle fasciculations was 73 and 33% in Groups II and III, respectively as against 90% in Group I. The incidence of postoperative myalgia was highest (86.67%) in Group I and lowest in Group III (60.0%). Conclusion: The technique of giving repeat bolus dose of propofol immediately after succinylcholine not only decreases the incidence and severity of fasciculations and postoperative myalgia, but also provides hemodynamic stability and satisfactory grade of relaxation for intubation.

Surgical face mask as a nappy

SIR—Use of the surgical facemask, for other than its intended application has already been documented (1,2). In newborns and children, prevention of soiling because of lack for bowel and bladder control under anesthesia is of paramount importance. In a developing country many parents cannot afford disposable diapers which cost around

Distance from Skin to Epidural Space: Correlation with Body Mass Index (BMI).

10–30. In our institute, intraoperatively, genitalia were either kept bared under the drapes or covered with undergarments.