Comparison of duration of neuromuscular blockade with atracurium in obese patients

Objective: To compare the mean duration of atracurium induced neuromuscular blockade in minutes when dosed according to real body weight [RBW] or ideal body weight [IBW] to obese patients undergoing abdominal surgeries under general anesthesia

Study Design: Randomized controlled trial

Place and Duration of Study: Department of Anesthesiology, National hospital defense Lahore, From March 2015 to March 2016

Material and Methods: One hundred and fifty [150] patients were selected for this study and divided in to two equal groups [75 patients in each group], group-I [experimental group] and group-II [control group]. Sample size was calculated with 80% power of test, 95% confidence interval taking mean and standard deviation of duration of atracurium induced neuromuscular blockade in minutes in both groups i.e. 74.6 +/- 37.56 in real body weight group versus 40.02 +/- 22.5 in ideal body weight group. Non probability consecutive sampling technique was used. SPSS version 16 was used for data analysis. Frequency and percentages were used to present categorical data and mean +/- standard deviation for numerical data. Independent sample t-test was applied to compare the significance of outcome variables. A p-value of <0.05 was considered statistically significant

Results: There was a prolong duration of action in experimental group [real body weight group] 69.64 +/- 3.11 minute versus 46.33 +/- 2.77 minute in control group [ideal body weight group] which suggests that dose of atracurium should be calculated and given on basis of ideal body weight in obese

Conclusion: It was observed in our clinical trial that body weight calculation and dosage of atracurium accordingly has altered duration for recovery from blockade, the results of the study showed that atracurium when used according to ideal body weight as compared to total body weight has reduced duration of action. So atracurium dose should be calculated according to ideal body weight rather than total body weight in obese patients

VATS without general anesthesia: initial experience of 18 cases

Background: General anesthesia and selective ventilation has long been the traditional anesthetic approach for video-assisted thoracoscopic surgery [VATS]. However it may not always be necessary or feasible in a certain variety of patients. VATS under locoregional anesthesia and sedation has proved to be a safer and more efficacious alternative to general anesthesia, especially in cases deemed unfit for the latter

Methodology: We retrospectively reviewed medical records of patients who underwent VATS under regional anesthesia/nerve blocks with sedation in three private hospitals from April 2014 to November 2015. VATS are conducted in these hospitals by the same anesthesia team and operated by a single surgeon. Eighteen patients included in the case-series were either considered high-risk for general anesthesia or required minor to intermediate surgery. None of the patients required endotracheal intubation or conversion to thoracotomy during the procedure

Results: Eighteen patients underwent successful VATS under locoregional anesthesia with sedation at our set-up from April 2014 to November 2015. The procedures included pleural biopsies, pleurodesis, empyema drainage, biopsies for mediastinal masses, lung tumors and apical infiltrates, all performed under video-assistance. There was no perioperative mortality or unanticipated ICU admission

Conclusion: VATS under locoregional anesthesia and sedation is a valuable, efficacious and safe alternative to general anesthesia that needs to be incorporated more frequently in the modern anesthesia practice

Medical errors related to look-alike and sound-alike drugs

Despite recent developments in the inventory management, introduction of electronic drug trolleys and cabinets, color coding of the filled syringes and many more interventions, medication errors could not be eliminated. The most common of these are syringe swap and human errors regarding wrong drug administration due to look-alike drug containers or sound-alike names of the drugs belonging to diverse groups. Many of the fatalities, that occur in third world countries due to these causes, go unnoticed and unregistered. This special article complements two special editorials on the same topic by Professor Joseph D. Tobias et al and Professor Robert Stoelting, a case report, a patient's perspective and a 'Cliniquiz' being published in the current issue of the journal. It discusses salient features of this issue as well as preventive measures and recommendations

Drug errors: a case of syringe swap

The journal presents this special issue dedicated to drug errors, with just two aspects highlighted; syringe swap and inadvertent wrong drug administration due to look-alike drug containers. This article gives the background of this decision and a victim's vivid narrative of her terrific experience related to drug error during anesthesia

Comparison of acid reducing property of tramadol and ranitidine given before cesarean section under general anesthesia

Intramuscular tramadol has been shown to reduce gastric acid secretion. We aimed to investigate its role in reducing the gastric acid contents and compared it with ranitidine in patients undergoing elective cesarean sections under general anesthesia. Sixty ASA-II parturients undergoing elective cesarean section were included in a randomixed double-blind study. The patients were randomly allocated to receive either tramadol 100 mg [n=30] or ranitidine 50 mg IM [n=30] 1 hour before general anesthesia. Gastric contents were collected using blind gastric aspiration after induction and at the end of the procedure. The patients receiving tiamadol had a lower, mean gastric fluid pll after induction and before recovery as compared to patients treated with ranitidine [3.5 +/- 1.7 vs. 5.8 +/- 1.5], and the difference was significant [P value=0.001]. A significantly higher proportion of newborns had a lower APGAR at 1 min in tramadol group as compared to ranitidine group [P value= 0.026] Nalbuphine consumption in first 12 hours after operation was reduced in the tramadol group. There was no significant difference in the incidence and severity of nausea, vomiting or any other side effect between the two groups. In comparison with ranitidine, the administration of tramadol in patients undergoing elective cesarean sections under GA resulted in significantly greater volume and acidity of the gastric contents, lower neonatal APGAR at 1 minute, reduced post operative opioid consumption and no change in the frequency of PONY

Can you stop this shivering, doctor?

Postoperative shivering and feeling of cold associated with it is rated as worse than pain by some patients. It has been a problem not only after general anesthesia, but also during and after spinal anesthesia. This editorial compliments an original article in this issue of 'Anesthesia, Pain and Intensive Care' on comparison of three different drugs for the treatment of postoperative shivering, and draws attention towards pathogenesis of shivering and its control. Shivering is not a point in time event and its cessation with pharmacological intervention does not guarantee against its recurrence

Comparison of dexamethasone and ondansetron for the prophylaxis of post operative nausea and vomiting in laparoscopic gynaecological procedures

Introduction: Post-operative nausea and vomiting [PONV] is one of the important complications after laparoscopic surgery resulting in patient dissatisfaction and consumption of healthcare resources

Objectives: We compared the efficacy of dexamethasone and ondansetron in preventing post operative nausea and vomiting in gynaecological laparoscopic surgeries

Methods: After approval from ethical committee and informed consent, the patients were randomly assigned to receive dexamethasone 8 mg or ondansetron 4 mg i.v. at induction. Postoperative PONV scores, pain scores, morphine consumption and Richmond Agitation sedation scores were compared one hourly for 6 hours and at 12 and 24 hours

Results: Both patient groups were similar in age, weight, height, duration of surgery and ASA distribution. No difference was observed in PONV scores at 1 hour [p=0.33], 2-3 hours [p=0.27], 4-6 hours [p=0.13] and 7-12 hours [test p=0.48]; first episode of vomiting [4.87 sd +/- 2.29 vs. 4.29 sd +/- 1.32 hours, p=0.59]; maximum pain scores at 1 hour [p=0.61], between 2-3 hours [p=0.32], 4-6 [p=0.47], 7-12 [p=0.57] and 13-24 hours [p=0.79]; and post-operative Richmond Agitation Sedation scores [p =0.33; 0.48, and 0.50 at 1-3, 4-6, and 7-12 hours]. Mean morphine consumption was similar in two groups at 1-3 hours [2.44 +/- 2.18 vs. 3.0 +/- 2.0 mg; p=0.24], 4-6 [3.73 +/- 2.85 vs. 4.41 +/- 2.72 mg; p=0.31], 7-12 [3.81 +/- 2.91 vs. 4.75 +/- 2.96 mg; p=0.18] and 13-24 hours intervals [3.94 +/- 2.97 vs. 4.80 +/- 2.97 mg; p=0.23]. The time to first occurrence of nausea was significantly delayed in dexamethasone group, [3.85 +/- 2.24 vs. 2.25 +/- 1.38 hours; p=0.02]

Conclusion: The efficacy of dexamethasone and ondansetron in preventing post-operative nausea and vomiting in gynaecological laparoscopic procedures is comparable; onset of nausea is significantly delayed in dexamethasone group

Euthanasia: is it really a bad idea?

'Euthanasia' or 'mercy killing' is a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering. The debate in favor of or against it is nothing new, but emanates from the days of Socrates, Plato and Hippocrates. Medical advances in the vital organ function support and treatments during later part of the twentieth century, and organ harvesting for transplantation have added newer dimension to this subject; whereas, religious teachings may not favor individual wishes. Financial and social cost of sustaining life of a incurable patient may force us to take unpopular decisions. The debate about euthanasia continues and is likely to continue for the times to come

Effect of injecting saline into epidural space before catheter insertion on frequency of intravascular placement

The objective of the study was to determine if injecting 10 ml saline before threading epidural catheter can decrease the accidental intravascular placement in epidural space. Interventional: experimental study. Department of Anaesthesia, Hameed Latif Hospital Lahore, affiliated with College of Physicians Surgeons Pakistan, from September 2008 to August 2009. One hundred healthy women requesting Epidural labour analgesia were prospectively randomized to receive either no epidural injection [dry group, n = 50] acting as a control or epidural 10 ml saline injection [saline group, n = 50] before epidural catheter placement. A nylon multiport catheter was then threaded 3 cm into the epidural space and the needle was removed. We diagnosed iv catheter placement if blood was freely aspirated, or if the mother became tachycardic after injection of epinephrine 15 microg. The groups were similar in age [P value=0.32]. We identified iv catheter placement in 2/50 saline group and 7/50 dry group patients [4% vs 14%, P value= 0.16]. Intravenous catheter placement was identified by initial blood aspiration [two saline, seven dry group patients]. No anesthetic complications occurred, including hypoxemia,patient complaint of difficulty swallowing, intrathecal catheter placement, respiratory arrest, or subsequent iv or intrathecal catheter migration. Our study results have shown that injecting 10 ml saline before threading epidural catheter has insignificant effect on decreasing the accidental intravascular placement in epidural space

Oral gabapentin reduces hemodynamic response to direct laryngoscopy and tracheal intubation

Laryngoscopy and tracheal intubation increase blood pressure [BP] and heart rate [HR]. We studied the effect of gabapentin 800 mg given orally one hour before surgery on hemodynamic responses to laryngoscopy and tracheal intubation. Sixty patients were randomly allocated to one of the two groups. Group I received 800 mg of gabapentin and Group II received placebo with sip of water one hour before the induction of anaesthesia. After standard induction technique, study variables, pulse and noninvasive BP [systolic, diastolic and mean] and HR were noted every minute for first five minutes then at 10 and 15 minutes. Relevant demographic data and study variables were recorded. Mean systolic BP with Gabapentin was lower compared to placebo but it was significant at 1min [136 +/- 22vs149 +/- 23], 2min [120 +/- 21vs136 +/- 24], 10min [107 +/- 12vs118 +/- 16] and 15 min [106 +/- 13vs116 +/- 13] after intubation [P<0.05]. Mean diastolic BP with gabapentin was significantly lower at 3min [69 +/- 15vs74 +/- 17] after intubation with P<0.05. Mean BP with gabapentin was significantly lower at 2min [91 +/- 18vs103 +/- 18], 10min [79 +/- 12vs88 +/- 13] and 15 min [79 +/- 14vs86 +/- 12] after intubation at P<0.05. Decrease in HR with gabapentin was significant at 10min [92 +/- 15vs101 +/- 18] and 15 min [87 +/- 14vs99 +/- 16] after intubation [p<0.05]. Oral gabapentin decreases the response to laryngoscopy and intubation on systolic BP at 2 min and 15 min; mean arterial pressure at 2, 10 and 15 min and HR at 10 and 15 min following laryngoscopy

causes, prevention and management of post spinal backache: an overview

Back pain is one of humanity's most frequent complaints, a common reason for physician visits and a major psychological, physical and economical burden. Although the frequency of backache is as high as 46% even after general anaesthesia, it was the major cause for 13.4% patients refusing spinal anaesthesia. Multiple factors are involved in the pathogenesis of postoperative back pain and include type and duration of surgery, duration of immobilization, and the position of the patient during spinal puncture. Diagnosis of back pain is not simple; contributing factors may include needle trauma, surgical positioning, and injection of saline or local anaesthetic into the interspinous ligaments, development of a supraspinous hematoma, excessive stretching of ligaments after relaxation of paraspinal muscles and localized trauma to the intervertebral disc. Its relationship with various types and sizes of spinal needle is yet to be confirmed. Some preventive aspects have been discussed. Acute post spinal backache usually resolves within 7 days without any treatment but the possibility of epidural abscess or epidural hematoma must be ruled out. Counselling, hot and cold massage, mild analgesics like paracetamol or topical NSAIDs ointments may be prescribed

Administration of local anaesthetics through epidural needle before catheter insertion does not improve the quality of anaesthesia or reduce catheter related complications

The objective of this study was to compare the effect of injecting local anaesthetics through epidural needle and catheter on quality of anaesthesia and catheter related complications. We randomized 60 patients into 2 equal groups; in the Needle Group [n=30], catheters were inserted after injection of a full dose of local anesthetic through the needle. In the Catheter Group [n=30], the catheters were inserted immediately after identification of the epidural space; local anesthetic was then injected via the catheter. The groups were compared for paresthesias, inability to advance the catheter, intravenouos or subarachnoid catheter placement; sensory and motor block were assessed 20 min after the injection of local anesthetic. Statistical analysis was performed by SPSS for Windows [version 10.0] Patient characteristics were analyzed using the t-test for independent groups. Block height, perioperative anesthesia quality and incidences of catheter related complications were analyzed using chi square test. Thoracic level sensory block and motor block was comparable in both the groups. Frequency of paresthesia during catheter placement was comparable; [23.3% versus 13.3% P=0.3]. Intra-vascular catheterization occurred in 23.3% versus 10% of patients in the catheter and needle groups, respectively [P=0.166]. Excellent surgical conditions were statistically similar in both the groups. Injecting local anaesthetic through the epidural needle before catheter placement does not reduce catheter-related complications or improve the qualityof epidural anesthesia

Measurement of the volume and pH of gastric contents using blind gastric aspiration

The volume and pH of the gastric contents was analyzed, using blind gastric aspiration, in 40 patients. Group 1 consisted of 20 patients undergoing elective Caesarian Section and group 2 consisted of 20 elective general surgical and gynaecological patients. The volume aspirated was 20.9ml +/- 12.03ml [mean +/- sd] in group 1 and 27.8 +/- 15.83 ml [mean +/- sd] in group 2. Volume ml/kg body weight was 0.31 +/- 0.18 ml/kg in group 1 and 0.45 +/- 0.28 ml/kg in group 2. pH was 3.11 +/- 1.17 in group 1 and 3.31 +/- 1.68 in group 2. There was no difference in the volume, volume per kg. Body weight or pH of the gastric contents between the two groups. We conclude that there is no difference in the volume or pH of the gastric contents between obstetric patients during labour and non obstetric patients