Vipin Kumar Goyal

Estudo comparativo entre propofol e etomidato em pacientes sob anestesia geral

BACKGROUND AND OBJECTIVES Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2mg/kg) and etomidate (0.3mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p>0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

Pé caído: uma complicação iatrogênica da anestesia espinhal

BACKGROUND AND OBJECTIVES Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. CASE REPORT A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). CONCLUSIONS Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention.

Pulmonary hypertension and post-operative outcome in renal transplant: A retrospective analysis of 170 patients

Background and Aims: Renal transplant is the best possible treatment for patients suffering with end-stage renal disease (ESRD). Cardiovascular events are the commonest factors contributing to perioperative morbidity and mortality in this population. These patients have a high incidence (up to 60%) of pulmonary hypertension (PH) and that may affect the perioperative outcome. Methods: In this study, we aimed to study the impact of PH on perioperative outcome after renal transplant. PH was defined as patients with pulmonary artery systolic pressure ≥35 mmHg on pre-operative echocardiography. Medical records of 170 patients who had undergone renal transplantation in the past 3 years were reviewed. Primary outcome was delayed graft functioning and secondary outcomes were perioperative complications such as hypotension, arrhythmias, need of post-operative mechanical ventilation, atelectasis and pulmonary oedema. Results: We observed 46.5% incidence of PH in ESRD patients. Compared to patients without PH, more patients with PH had postoperative hypotension (26.58% vs. 9.89%, P = 0.004) and delayed graft functioning (8.8% vs. 1.1%, P = 0.026). On multivariate analysis, however, PH was not an independent predictor of delayed graft functioning. Conclusion: In ESRD patients, although PH is not an independent predictor of delayed graft functioning, patients having PH are more prone for perioperative hypotension and delayed graft functioning after renal transplant.

Effect of preoperative incentive spirometry on fentanyl-induced cough: a prospective, randomized, controlled study

Background Fentanyl-induced cough (FIC) has a reported incidence of 13–65% on induction of anesthesia. Incentive spirometry (IS) creates forceful inspiration, while stretching pulmonary receptors. We postulated that spirometry just before the fentanyl (F) bolus would decrease the incidence and severity of FIC. Methods This study enrolled 200 patients aged 18–60 years and with American Society of Anesthesiologists status I or II. The patients were allocated to two groups of 100 patients each depending on whether they received preoperative incentive spirometry before fentanyl administration. Patients in the F+IS group performed incentive spirometry 10 times just before an intravenous bolus of 3 µg/kg fentanyl in the operating room. The onset time and number of coughs after fentanyl injection were recorded as primary outcomes. Any significant changes in blood pressure, heart rate, or adverse effects of the drug were recorded as secondary outcomes. Results Patients in the F+IS group had a significantly lower incidence of FIC than in the F group (6% vs. 26%) (P < 0.05). The severity of cough in the F+IS group was also significantly lower than that in group F (mild, 5 vs. 17; moderate 1 vs. 7; severe, 0 vs. 2) (P < 0.05). The median onset time was comparable in both groups (9 s [range: 6–12 s] in both groups). Conclusions Preoperative incentive spirometry significantly reduces the incidence and severity of FIC when performed just before fentanyl administration.

A comparative study between propofol and etomidate in patients under general anesthesia

BACKGROUND AND OBJECTIVES Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2mg/kg) and etomidate (0.3mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p>0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

Anesthetic management of a case of spontaneous rupture of diaphragm.

Sir, A 58-year-old male patient presented with a history of sudden onset of the left upper quadrant pain and vomiting from 6 days following the lifting of bucket filled with water. He also had a history of the left lower chest pain on inspiration, dyspnea on lying supine, decrease appetite and constipation. Vitals were almost normal at admission. Oxygen saturation was 90%. On auscultation air entry was absent over left lower hemithorax. Routine blood tests were normal. Arterial blood gas showed respiratory alkalosis with mild hypoxemia (pH 7.50, pCO2 30 mmHg and pO2 64 mmHg). Electrocardiogram showed “t” wave inversion in leads V1, V2 and V3. A plain erect chest radiograph showed upward shifting of the left side of hemidiaphragm, air filled shadow of stomach occupying lower half of left hemithorax, compression of the left lung, shifting of the trachea and mediastinal structures to the right side [Figure 1]. In the operating room, standard anesthesia monitors were attached. A rapid sequence induction (RSI) of anesthesia was done with thiopentone, succinylcholine, and fentanyl. Due to nonavailability of double lumen tube trachea was intubated with number 8.0 standard endotracheal tube (ETT) that was intentionally inserted in the right main bronchus and was fixed at 26.0 cm. A pressure controlled mode was initiated. Anesthesia was maintained on oxygen in the air and isoflurane. Laparotomy via midline approach revealed a tear of approximately 5 cm at the lateral side of left hemidiaphragm. Stomach was pulled down through the rent along with gangrenous part of omentum. Gastropexy was done and diaphragm tear was repaired. Gangrenous part of omentum was resected out. ETT was withdrawn to 22 cm at upper incisor and bilateral air entry was confirmed. Chest drain was placed. At the end of surgery, patient was extubated in the operating room with acceptable vital parameters. Figure 1 X-ray chest posteroanterior view showing left diaphragmatic hernia Spontaneous rupture of the diaphragm is extremely rare with limited literature. Spontaneous rupture can be due to violent cough,[1,2] during vaginal delivery[3] physical activity,[2] violent vomiting and defecation.[4] Sudden and violent Valsalva maneuver with increased intraabdominal pressure is main denominator in these cases.[5] Diagnosis is difficult due to nonspecific clinical presentation such as upper quadrant abdominal pain, vomiting, and constipation.[6] This is mostly associated with dyspnea, tachycardia and hypotension. Chest radiograph may help in diagnosis, but has poor sensitivity and specificity. Radiographic finding includes herniation of abdominal viscera into the thoracic cavity, compression of ipsilateral lung and displacement of mediastinum to the opposite side. “Collar sign” is the presence of a large bulla between the abdomen and the chest, with a constriction at the diaphragmatic level is specific of a diaphragmatic defect.[5] Early complications may include strangulation of intestine that can terminate in rupture and gangrene formation. Peritonitis and pleural effusion may be the sequel. Early intervention includes oxygenation, correction of fluid deficit, gastric decompression etc. Emergent surgical intervention is usually required in view of high mortality and morbidity. The causative factor for diaphragm rupture would be the raised intraabdominal pressure during lifting of a heavy object. Other possible etiologies like congenital diaphragmatic hernia or ischemic process was ruled out by intraoperative findings. Anesthetic management of these patients is quite challenging in view of an emergency nature of surgery with inadequate time to patient optimization, unstable hemodynamics, high probability of hypoxemia and rapid desaturation, full stomach, fluid deficit, electrolyte imbalance and need for one lung ventilation. These patients often require the securing of wide bore intravenous access or central venous cannulation, beat to beat blood pressure monitoring if hemodynamically unstable. RSI in these patients may cause rapid desaturation because of already decreased functional residual capacity. During mechanical ventilation, lung protective strategy should be applied with low tidal volume and positive end expiratory pressure. Postoperatively, patient can be extubated in the operating room if vital parameters allow. Grossly ruptured and hemodynamically unstable patient should be allowed to ventilate postoperatively. Adequate analgesia (epidural analgesia) in the postoperative period can help in early recovery. Patient controlled analgesia can be used if epidural was placed.

Electrocautery induced artifactual ST segment depression in leads II, III and aVF on intra-operative 5-lead electrocardiogram.

To the Editor, We describe a case of electrocautery-induced artifactual inferior wall ischemic changes in a 31 year old male patient with chronic kidney disease (CKD) undergoing repeat live donor kidney transplantation. He was a known case of CKD since last 7 years and undergone live donor kidney transplantation 6 years back. He was on maintenance hemodialysis twice a week again since a year. He was continued to be hypertensive since last 10 years even after kidney transplantation and was on three anti hypertensive medications. He had dyspnea on exertion class II and New York Heart Association status II. His preoperative 12-lead electrocardiogram (ECG) showed normal sinus rhythm with left ventricular hypertrophy (LVH). Echocardiogram reported concentric LVH, mild mitral regurgitation, mild pulmonary artery hypertension, minimal pericardial effusion and left ventricular ejection fraction of 40 %. All anti hypertensive medications were continued till morning on day of surgery. In the operating room, 5-lead ECG, pulse oximetry and non-invasive blood pressure monitoring was applied on non-fistula arm. Anesthesia was induced with fentanyl, propofol and atracurium. Right internal jugular central venous catheter was placed under ultrasound guidance and surgery was allowed to start. Immediately after skin incision, ST segment depression was noted in lead II (Fig. 1a). He was hemodynamically stable with blood pressure of 147/89 mm Hg and pulse rate of 88 per minute. ST segment depressions were temporary and intermittent with the use of unipolar electrocautery by surgeon. Correct placement of ECG electrodes was confirmed and all lead ECG view was seen on monitor to look at other leads for similar changes. It was noticed that ST segment depressions were present in lead II, III and aVF with slight ST elevation in aVR (Fig. 1b). These intermittent and temporary ECG changes were present and reproducible throughout the surgery. Electrocautery (anode) plate was applied on posterior aspect of upper part of right thigh, quite away from the ECG electrodes. Monitor used was one attached to Datex-Ohmeda S/5 Avance anesthesia workstation and was in routine use without similar occurrence in other cases. Post operative his 12-lead ECG was same as preoperative and enzyme marker (troponin T, troponin I and CK-MB) were negative for ischemia or infarction. Electrocautery induced artifact in intraoperative ECG showing ST changes have been reported previously. Jain et al. [1, 2] reported electrocautery induced ST segment depression in two different patients with coronary artery disease undergoing non cardiac surgeries. In an another case reported by Jain et al. [3] showed ST segment elevation in lead V5 with concurrent ST depression in lead II, in a CKD patient undergoing cadaveric kidney transplantation. Similar ST segment depression was also reported by Ketchey et al. [4]. In present case ST segment depressions were noted in lead II, III and aVF, and this point toward diagnosis of inferior wall ischemia or it can be a mirror image of ischemia in another area (e.g. anterior ischemia) or other non-ischemic diseases. Being an American society of anesthesiologist physical status grade III patient, kidney transplant recipient patient is always at great suspicion for perioperative cardiac arrhythmias, myocardial ischemia and infarction. The five S. L. Solanki (&) K. Kishore V. K. Goyal Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae-Bareilly Road, Lucknow 226014, India e-mail: me_sohans@yahoo.co.in