Vr Hemanth Kumar

Intraoperative anaphylaxis to ranitidine during cesarean section

Ranitidine, a widely used drug, is known to be well tolerated. This case report illustrates a severe anaphylactic reaction after a single intravenous dose of 50 mg ranitidine during the emergency cesarean section under spinal anesthesia. Anaphylaxis was successfully managed with Inj. adrenaline, Inj. hydrocortisone, ventilatory, and inotropic support following which she had a full recovery. Awareness of this rare but fatal adverse reaction to this commonly used drug could help in early recognition of the event if faced suddenly.

Assessment of suitability of i-gel and laryngeal mask airway-supreme for controlled ventilation in anesthetized paralyzed patients: A prospective randomized trial

Context: Laryngeal mask airway supreme (LMA-S) has an inflatable cuff while i-gel has a noninflatable cuff made of thermoplastic elastomer. Aims: To study the efficacy of ventilation and the laryngeal seal pressures (LSPs) with either device. Our secondary objectives were to compare the ease of insertion, adequacy of positioning the device, hemodynamic response to device insertion, and any postoperative oropharyngeal morbidity. Settings and Design: A prospective, randomized, single-blinded study at Teaching Medical School in South India. Materials and Methods: Forty-two patients posted for surgery under general anesthesia were randomly divided into two groups - LMA-S and i-gel. After a standardized premedication and anesthesia induction sequence, the supra-glottic devices were introduced. Ease of insertion was assessed from the number of attempts taken to insert, insertion time, and any maneuvers required to insert the device. Position of the device was assessed by the ease of gastric catheter placement and the fibreoptic grading of laryngeal visualization. Efficacy of ventilation was determined from the LSP, peak inspiratory pressure (PIP), and end-tidal carbon dioxide (EtCO2)values. Any postoperative oropharyngeal morbidity was also recorded. Statistical Analysis: Descriptive analysis was reported as a mean and standard deviation, median, and range of continuous variables. Demographics were analyzed using a unpaired t-test for parametric data and Chi-square test for nonparametric data. Respiratory and hemodynamic data was analyzed using one-way ANOVA to find statistical difference within and between the two groups. Results: LMA-S was successfully inserted in 95% of patients and i-gel in 85.5% of patients. There was a significant difference (P = 0.021) in the LSPs between the two groups (18.15 cmH2O in LMA-S and 21.28 cmH2O in the i-gel group). There was no significant difference in the PIPs, leak fraction, and the EtCO2values. Conclusion: Both devices are suitable for positive pressure ventilation (PPV) in anesthetized paralyzed patients. However, i-gel gives a better laryngeal seal when compared to LMA-S and may be chosen preferentially for PPV.

Estimation of effect-site concentration of propofol for laryngeal mask airway insertion using fentanyl or morphine as adjuvant

Background and Aims: Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides jaw relaxation and suppression of upper airway reflexes. Propofol can provide these conditions especially when combined with narcotics. This study had been designed to find out the effect-site concentration (EC 50 ) of propofol using target controlled infusion (TCI) when fentanyl or morphine is added as an adjuvant. Methods: Patients satisfying inclusion criteria were divided into fentanyl and morphine groups. Intravenous glycopyrrolate 0.2 mg was given 15 min before induction. Patients were given either intravenous fentanyl (1 μg/kg) or morphine (0.1 mg/kg) before propofol infusion depending on the group. Patients in either groups were induced by continuous infusion of propofol at an EC of 6 μg/mL by TCI with Schneider pharmacokinetic model. The LMA supreme of appropriate size was inserted 1 min after achieving target concentration. Patient movement at LMA insertion or within 1 min of insertion was classified as failure. For subsequent patients, the target EC was increased/decreased depending on previous patients′ response. Dixons up and down method was used to determine the EC 50. The EC 50 is defined as the mean of crossover midpoints in each pair of failure to success. Results: The EC 50 of propofol in the fentanyl group for LMA insertion was 5.95 ± 0.6 μg/ml and morphine group was 5.75 ± 0.8 μg/ml. No significant difference in insertion conditions was noticed between the two groups (P = 0.3). Conclusion: We conclude that there was no significant difference in propofol EC 50 for insertion of LMA and insertion conditions were similar when fentanyl or morphine was used as an adjuvant drug.

Anesthetic management of a patient presenting with eclampsia

Eclampsia is one of the most common emergencies encountered by anesthesiologists which involve a safe journey of two lives. The definition, etiology, pathophysiology, treatment guidelines along with a special reference to management of labour pain and caesarean section are discussed. Eclampsia is commonly faced challenging case in our day to day anaesthesia practice,but less is discussed in our anaesthesia text books. Lot of controversies with regard to fluid management and monitoring still remain unanswered

Rapid and reliable smooth extubation – Comparison of fentanyl with dexmedetomidine: A randomized, double-blind clinical trial

Background: Fentanyl and dexmedetomidine have been tried to attenuate airway and circulatory reflexes during emergence and extubation individually but have not been compared with respect to the level of sedation to evolve a reliable technique for rapid and smooth extubation. Aim: To compare the effects of fentanyl and dexmedetomidine in attenuating airway and circulatory reflexes during emergence and extubation of the endotracheal tube. Setting and Design: This double-blind, randomized, controlled study was done in patients undergoing surgery under general anesthesia belonging to the American Society of Anesthesiologists physical status 1 or 2. Methodology: All patients received a standardized anesthetic protocol. Patients were randomized to receive either fentanyl 1 μg/kg or dexmedetomidine 0.75 μg/kg. Fifteen minutes before expected last surgical suture, isoflurane was cutoff and equal amount of test solution was given when train-of-four ratio was 0.3. The degree of sedation, airway, and circulatory responses at the time of suction and extubation were analyzed. Statistical Analysis Used: Chi-square test for nonparametric data and t-test for parametric data. Results: Heart rate (HR) was comparable in both the groups until endotracheal extubation. Later, there was rise in HR in fentanyl group. There was stastisticaly significant drop in blood pressure at 5 min after test drug administration in both the groups. Airway response for suctioning and extubation was better in dexmedetomidine group and it was associated with better sedation score than fentanyl group. Conclusion: Single dose of 0.75 μg/kg dexmedetomidine given 15 min before extubation provides smooth extubation when compared to fentanyl.

Comparison of efficacy of three subanesthetic doses of ketamine in allaying procedural discomfort during establishment of subarachnoid block: A randomized double-blind trial.

Background: Procedural discomfort is experienced by patients during the establishment of subarachnoid block even after good preoperative counseling and adequate premedication. To enhance comfort, procedural sedation that would provide good analgesia, faster recovery, and amnesia is necessary. Materials and Methods: Patients with American Society of Anesthesiologists Status I and II posted for elective surgeries under subarachnoid block were premedicated with injection midazolam 0.05 mg/kg and preloaded with 10 ml/kg ringer lactate solution. They were randomized into three groups of 30 each. Group K0.3 received ketamine 0.3 mg/kg, Group K0.4 received ketamine 0.4 mg/kg and Group K0.5 received ketamine 0.5 mg/kg intravenously. University of Michigan sedation score, ease of positioning, prick response, verbal response, hallucinations, recall of procedure, and patient satisfaction were evaluated. Results: There was statistically significant difference in sedation among the three groups. Increased dose necessitated help of two persons to position the patient, which showed statistically significant difference. Verbal response was seen early in Group K0.3 (4.67 ± 2.84 min). There was no recall of experience of subarachnoid block procedure in any of the groups in spite of back muscle contraction or patient movement. Hence, all patients in all three groups were satisfied and were willing to undergo subarachnoid block, if the situation arises. Conclusion: Ketamine in the dose of 0.3 mg/kg provided sufficient sedation for allaying procedural discomfort due to less sedation, less positional difficulty, early verbal response, no hallucinations, no recall of performance of procedure, and good patient satisfaction.

Study of patient satisfaction and self-expressed problems after emergency caesarean delivery under subarachnoid block

Background and Aims: Subarachnoid block is one of the common modes of anaesthesia opted for emergency caesarean section, if the maternal and foetal conditions are favourable. Various factors influence the quality of care administered during the procedure. This questionnaire based study was undertaken to look for self-expressed problems in peri-operative period in patients undergoing emergency caesarean surgery under subarachnoid block. Methods: All the parturients who underwent emergency caesarean section under subarachnoid block during 6 months period were distributed a questionnaire in post-operative period. They were encouraged to fill and return the form within 15 days. Patient satisfaction and the self-expressed problems were analysed at the end of 6 months. Results: One hundred and seventy five out of 220 parturients responded. 58.3% of them said that they were explained about the anaesthesia prior to surgery and 85.3% overall remained anxious. With people around them, 93.1% of them felt comfortable and 91.4% expressed that they were made comfortable inside the theatre. The self-expressed problems were shivering (43.4%), breathlessness (21.7%), pain (20%), post-operative headache (15.4%) and backache (19.4%). Parturients who heard their babies cry was 85.1%. After their babies were shown after delivery, 77.1% mothers slept well; 86.9% fed their babies within 4 h of delivery. Conclusion: Pre-operative communication in emergency caesarean section by health personnel did not reduce the anxiety level, which shows that communication was ineffective. Intra-operative psychological support like making the patient comfortable, showing baby to mother and early breast feeding improve bonding between child and mother and essentially contribute to patient satisfaction.

A comparative study between Truview PCD laryngoscope and Macintosh laryngoscope in viewing glottic opening and ease of intubation: A crossover study

Background: TruviewPCD laryngoscope is specially designed to aid positioning of the endotracheal tube as well as to record entry of the tube into glottis. Aim of the study is to compare the view of glottic opening and ease of intubation between TruviewPCD laryngoscope and Macintosh laryngoscope in patients undergoing general anesthesia (GA). Methodology: Two hundred patients undergoing elective surgery, under GA were randomized into two groups, Group TV and Group ML. In Group TV, TrueviewPCD laryngoscope was used initially to visualize the vocal cords for Cormack and Lehane grading (CLG) and to spray the vocal cords with 10% lignocaine. Then the patient was ventilated for 1 min and Macintosh laryngoscope was used to visualize the vocal cords for CLG and proceed with intubation. In Group ML, Macintosh laryngoscope was used initially and later TruviewPCD laryngoscope. Time to intubation, CLG, number of attempts and hemodynamic parameters were recorded. Results: Ninety-six and 89 patients had CLG1 visualization when TruviewPCD laryngoscope was used as 1st and 2nd device respectively compared to 41 and 68 with Macintosh laryngoscope (P = 0.00). Four patients had CLG 4 visualization with Macintosh laryngoscope that turned out to be grade II visualization with TruviewPCD laryngoscope (P = 0.00). Mean time taken for intubation with TruviewPCD and Macintosh laryngoscope was 21.10 ± 5.64 s and 15.79 ± 2.76 s respectively (P = 0.00). Conclusion: Better visualization with lesser CLG was found with TruviewPCD laryngoscope but it took longer time for intubation than Macintosh laryngoscope. The hemodynamic response to intubation was significantly less with the use of TruviewPCD laryngoscope when compared to that of Macintosh laryngoscope.

Mediation of Attitude toward Advertisements in The Relationship between Advertisements and Purchase Intention

In present bailiwick of sales promotion, advertisements act as an accelerating puppet to lure the customers to think about their products. the escalated competition between product promoters engulfed them to go back to very purpose of advertisement which is to inform, attract and create awareness about their products among the competitors. the momentous study examines the interrelationship between advertisements, attitude toward advertisements and purchase intention. Further some, this study concentrates on the mediating role of attitude towards advertisements in between the purchase intention and advertisements. the study was conducted among 320 common people from various walks of life in Chennai city was used for the study. The hypotheses were examined by linear regression and Sobel test. Findings reveled that both advertisements and attitude towards advertisements have a positive influence on purchase intention and also the mediating element attitude towards advertisements have a partial relationship between advertisements and purchase intentions.

Efficacy of dexmedetomidine infusion for procedural comfort and intraoperative sedation in patients undergoing surgeries with subarachnoid block: A randomized double-blind clinical trial

Introduction: There is increasing evidence to include sedation as an integral part of regional anesthesia to ensure patient comfort. This may compromise patient cooperation, an important component of regional anesthesia. We decided to determine the efficacy of dexmedetomidine (0.3 μg/kg/h and 0.5 μg/kg/h) for allaying procedural discomfort and ensuring their cooperation in patients undergoing surgery with subarachnoid block. Setting: Tertiary care center. Materials and Methods: Sixty patients with the American Society of Anesthesiologists physical status Class I and II posted for surgeries under subarachnoid block were randomized into two groups of 30 each to receive dexmedetomidine in a loading dose of 1 μg/kg in both groups followed by continuous infusion of 0.3 μg/kg/h in Group D 0.3 and 0.5 μg/kg/h in Group D 0.5. Observer assessment sedation score, ease of positioning score, response to spinal needle insertion, hemodynamic parameters, patient satisfaction (PS) score, and surgeon satisfaction (SS) score were evaluated. Results: Median observer Assessment Sedation Score ranged between four and three at all times during dexmedetomidine infusion in Group D 0.3. In Group D 0.5, median Observer assessment of alertness/sedation scale ranged between three and two. Ease of positioning (P = 1.000) and response to spinal needle insertion (P = 0.521) were comparable in both groups. PS was higher in Group D 0.5 as compared to Group D 0.3. SS score was comparable in both the groups. Conclusion: Intravenous dexmedetomidine infusion 0.3 μg/kg/h produces effective sedation in patients undergoing surgery with spinal anesthesia while ensuring patient cooperation for positioning and without any recall of the procedure in postoperative period.