Prevention of hypotension during propofol induction: a comparison of preloading with 3.5% polymers of degraded gelatin (Haemaccel) and intravenous ephedrine.

The present study compared the efficacy of preloading with colloid "Haemaccel" with vasoconstrictor (intravenous ephedrine sulphate) in preventing hypotension during propofol induction. This prospective, randomized study included 120 patients of Amercan Society of Anaesthesiologists (ASA) physical status I and II ageing 21 to 50 years of both gender coming for routine surgery. Patients were randomly allocated into three groups with 40 patients in each. Group A (control) did not receive any study medication, group B received Haemaccel (10 ml/kg intravenously over 10-15 minutes) and group C received injection ephedrine (0.2 mg/kg iv) prior to induction of anaesthesia. Propofol (2.5 mg/kg iv) was used for induction of anaesthesia. Heart rate and blood pressure were recorded before induction (baseline) and then every minute for 5 minutes after administering propofol. Anaesthesia was continued with standard technique thereafter. Hypotension was defined as fall in systolic blood pressure more than 20% from the basal value. The incidence of hypotension in Haemaccel (23.1%) or ephedrine group (22.5%) was significantly less than the control group (67.5%, P<0.01). We conclude that though preloading with colloid (Haemaccel) or prior injection of sympathomimetic (ephedrine) are not fully efficacious in preventing hypotension caused by propofol induction, both decrease the incidence in significant number of patients with heart rate less than baseline value in the colloid group.

Port exteriorization appendectomy: is it the future?

The time honoured surgical procedure open appendectomy seems to be on the decline, it may be replaced in the modern era by laparoscopic appendectomy ("in appendectomy") performed with three trocars, or by the port exteriorization appendectomy ("out appendectomy") which can be done with two ports or even one. These techniques combine the benefits of decreased tissue trauma and operative time in addition to other advantages of minimal invasion. We conducted this study to know the effectiveness of Port Exteriorization Appendectomy, to analyze its complications and to assess the conversion rate. A one year prospective study consisted of fifty cases; a combination of emergency and elective group. They were operated under general anaesthesia and different variables were documented. Mean operative time, conversion rate, hospital stay, complications and patient satisfaction. There were 27 females with the (F: M) ratio of 1.17:1. The operative time of 23.3 mins, conversion in 4 (8.0%) patients and 2.4 days of hospital stay contributed to 86.0% operative success rate. Surgical site infection was seen in 5 (10.0%) patients and one (2.0%) developed pelvic abscess. On analysis of the satisfaction level, 44(93.6%) were completely satisfied and one (2.1%) patient seemed disappointed with the technique for cosmesis though, 42 (89.3%) remained completely satisfied and 5(10.7%) didn't like their scars. Port exteriorization appendectomy's efficacy can be verified by 86.0% success rate, operative time of 23.3 mins, indoor stay of 2.4 days, and minimal undesirable sequlae. However, more authentic results could be obtained if this technique is compared to open or laparoscopic appendectomy in a well designed randomized controlled clinical trial.

Fluoroscopy guided chemical lumbar sympathectomy for lower limb ischaemic ulcers.

The purpose of this study was to assess the effectiveness of chemical lumbar sympathectomy in relieving pain and healing ischaemic ulcers in patients with peripheral vascular diseases. Thirty-one consecutive patients with ischaemic/ gangrenous lower limb ulcers, referred to the BPKIHS, Pain Clinic were observed prospectively after chemical lumbar sympathectomy using modified Reid Technique with 3 ml of 70% alcohol each at L2 and L3 level under fluoroscopic guidance. Pain relief and ulcer healing were noted in the follow up. Moreover, patients' abilities to resume at least part of their day to day work were also noted at three months follow up. Of the total 31 patients, 16 had Buerger's disease and the remaining 15 had non-Buerger's ischaemic ulcers of which 7 were diabetic. There was significant decrease in the pain score from mean+/-SD of 8.3+/-0.9 (pre-block) to 4.2+/-2.5 (post-block after 3 days) in zero to 10 Numerical Analogue Scale (NAS). By 3 months, 6 patients declined for follow up; 19(76%) of the remaining 25 patients reported pain relief, 18(72%) reported healing or decrease in the size of ulcers and 11(44%) were able to resume at least part of their usual work. Minor complications occurred in 5 patients and amputation was needed in 6 patients. Fluoroscopy- guided chemical lumbar sympathectomy is feasible, safe and effective in relieving pain and promoting ulcer healing in patients with ischaemic lower limb ulcers due both to Buerger's disease and non-Buerger's peripheral vascular diseases.

Brachial plexus block as a sole anaesthetic technique in upper extremity fracture/dislocation in children: subclavian perivascular vs parascalene approach.

OBJECTIVE: To compare parascalene approach of brachial plexus block with the classical subclavian perivascular approach as a sole anaesthetic technique in children undergoing closed manipulation for fracture/dislocation around the elbow. MATERIALS AND METHODS: Sixty children (age 6-13 years) undergoing closed manipulation for fracture/dislocation around the elbow were randomly assigned to two groups, Group I (n=30) receiving brachial plexus block using Winnie's classical subclavian perivascular approach and Group II (n=30) receiving brachial plexus block using parascalene approach described by Dalens. Time required for performing the block, onset of analgesia, sensory block to pin prick, adequacy of relaxation, complications and acceptance of the technique to the children, parents and the surgeons were compared. RESULTS: Time required for performing the block (6.3+/-2.2 min vs. 8.2+/-2.4 min), onset of subjective analgesia (4.1+/-1.6 min vs. 5.2+/-1.4 min) and onset of sensory block to pinprick (6.8+/-2.1 min vs. 8.6+/-1.7 min) were significantly shorter in Group I as compared to Group II (p<0.01). Acceptance of the techniques by the children, parents and the surgeons, and the overall success rates were high and comparable between the groups. Complications were minor and the incidence was low in both the groups except Horner's syndrome in 46.7% of patients in Group II. CONCLUSION: Parascalene approach to brachial plexus block is comparable to classical subclavian perivascular approach in safety, success rate and acceptance in children undergoing closed manipulation and reduction of fracture/dislocation around the elbow.

Percutaneous dilational tracheostomy: an initial experience in community based teaching hospital.

Percutaneous dilational tracheostomy (PDT) is frequently performed in the intensive care unit to prevent the long term complications associated with prolonged endotracheal intubation. OBJECTIVE: To report the analysis of our experience with percutaneous dilation tracheostomy. STUDY DESIGN: A prospective documentation of 40 patients who received percutaneous dilational tracheostomy in a multidisciplinary intensive care unit during a 12-month period. METHOD: The patients demographic, indications of intubation and PDT, time required to perform the procedure, complications and the outcome of these patients in the intensive care unit were noted. RESULT: Among 425 patients, 40 underwent percutaneous dilational tracheostomy that included 22 females and 18 males with the median age of 35 years. Prolonged ventilatory support was the most common indication for tracheostomy. The average duration of intubation before PDT was 5 days. Median procedure time was 20 minutes. Complications included minor bleeding in two (5%), subcutaneous emphysema with pneumothorax in two patients (5%), tracheal stenosis in three (7.5%), tracheo-esophageal fistula and glottic granuloma in one patient each (2.5%). Among forty patients, 28 (70%) were discharged to the ward, 8 died in intensive care unit and 4 left hospital against medical advice. CONCLUSION: Percutaneous dilational tracheostomy is a safe, quick and effective way for long term airway management in critically ill patients.