Efficacy and safety of dexmedetomidine as an intrathecal agent: a dose finding clinical study

Background and Objectives: Dexmedetomidine is increasingly being used in regional anesthesia as an adjuvant but there is no consensus on exact minimal and safe dose when used intrathecally. The present study was conducted to evaluate the efficacy of three different doses of dexmedetomidine when given intrathecally as an adjuvant to bupivacaine in patients undergoing lower abdominal surgery

Methodology: After taking ethical committee approval, and obtaining patients consent, 60 American Society of Anesthesiologist [ASA] physical status I and II patients in the age group of 25-60 years undergoing lower abdominal surgeries were divided randomly into three groups in this randomized double blind study. An intrathecal dose of 2.5 ml of 0.5% hyperbaric bupivacaine was administered to all patients supplemented with dexmedetomidine. In Group A 5 microg, Group B 7.5 microg and in Group C 10 microg of dexmedetomidine was administered with a volume of 3ml of study drug in each group. The onset time, time to peak sensory level, motor blockade, sedation, duration of motor block, analgesia and any adverse effects were noted. At the end of the study, data were compiled and analyzed with appropriate statistical tests

Results: Demographic profile was comparable in all the three groups. The time to onset of sensory block in Group C [1.55 +/- 0.510 mm] was significantly lower than Group A [2.15 +/- 0.745 min] and Group B [2.20 +/- 0.410 min]. Sensory regression by two segments was significantly higher in Group C [220.65 +/- 25.86 min] as compared to Group A [104.7 +/- 25.5min] and Group B [145.10 +/- 24.54 min]. [p < 0.05] The duration of motor block was shortest in Group A [243.8 +/- 22.0 min] as compared to Group B [305.4 +/- 35.8 min] and Group C [387.0 +/- 39.4 min]. The visual analogue scale score for pain was lesser in Group C as compared to the other two groups

Conclusion: Optimal dose of dexmedetomidine is difficult to define especially with prolonged duration of sensory and motor blockade in a dose dependent manner with minimal increase in side effects with higher doses. However, we conclude that 7.5 ug seems to be just optimal intrathecal dose of dexmedetomidine and can be used safely and effectively in lower abdominal surgeries

New and old oral anticoagulants in anesthesia practice: a balancing approach

For decades, vitamin K antagonist warfarin has been used for thromboprophylaxis or stroke prevention in atrial fibrillation. Recently, direct thrombin inhibitor - dabigatran and factor Xa inhibitors - rivaroxaban and apixaban, have emerged as alternatives to warfarin. The perioperative management of antithrombotic therapy involves establishing a balance between hemorrhagic risk and thrombotic risk. Routine coagulation assays like prothrombin time and activated partial thromboplastin time provide a crude estimation of their activity. Further, no specific antidotes are available to reverse their effect. These drugs are discontinued before elective surgery and timing is based on the patient's renal status also. For emergency surgery or bleeding, the management includes the principles of bleeding control; hemodialysis may be effective for dabigatran. Prothrombin complex concentrates are found to be more effective than frozen plasma but more studies are warranted

Changing anesthesia trends in cardiothoracic surgeries: a fast changing perspective

Off late, many complicated procedures are being performed throughout the globe in cardiothoracic surgery departments. Many of these advancements can be attributed to advancements in anesthesia techniques, availability of newer and safer anesthetic drugs. However, such role has never been stressed upon whereby advancements became possible in cardiothoracic surgeries. However the journey of advancements and refining of surgical and anesthetic techniques is never ending. The current narrative review throws light on the facts due to which cardiothoracic surgery has become highly safe

Recent advances in pre-eclampsia management: an anesthesiologist's perspective

Pre-eclampsia is an important cause of mortality and morbidity in parturients with varied presentations and controversial pathophysiology. The central pathology is a profound vasoconstriction in the vasculature leading to volume contraction and placental hypoperfusion. The management mainly involves a multi-disciplinary approach with the anesthesiologist playing a significant role for a positive outcome. Anesthesia for such parturients remains a challenge and starts with provision of labor analgesia which should be offered to all preeclamptic parturients. The neuraxial techniques of analgesia are most favourable for adequate pain relief and if contraindicated, intravenous PCA technique with the use of opioids should be used. Recent studies show favourable maternal and fetal outcomes with the use of patient controlled epidural analgesia technique with the combination of lower concentrations of local anesthetics with opioids. Regional anesthesia should be preferred in these parturients for cesarean section if not contraindicated. If general anesthesia is indicated, the techniques should be modified to prevent any stress response. A careful and prompt use of oxytocics should be done in all cases as the incidence of postpartum hemorrhage is high in these parturients

Long term neurotoxicity by general anesthetics in infants

Development of neurotoxicity in infants and children who had been exposed to general anesthetics has garnered attention in recent times and sparked vigorous debates. The effects range from learning disability, cognitive defects to development of neurodegenerative diseases like Alzheimer's disease in later life. Theories to explain these changes are calcium dysregulation leading to apoptosis, altered neurogenesis, accumulation of degenerative proteins like [3 amyloid and many others. A large volume of literature has accumulated in the form of animal and human studies which have implicated general anesthetic drugs like ketamine, propofol, volatile agents, and benzodiazepines in the development of neurodegenerative conditions in later life. These studies being retrospective are associated with a good deal of methodological flaws. Hence a direct cause effect relationship is yet to be firmly established. In the present scenario, it would be prudent for the anaesthesiologists, to be aware of the possible existence of such an association. In the meantime, further research and evidence in this arena is demanded

Perioperative hypothermia in pediatric patients: diagnosis, prevention and management

Hpothermia is the most common perioperative disturbance in pediatric patients. Pediatric patients are highly vulnerable to hypothermia and its associated complications, e.g. respiratory embarrassment, metabolic acidosis, hypoglycemia, hypoxemia, cardiac disturbances, coagulopathy, and a higher incidence of wound infection etc. This higher vulnerability is mainly due to increased heat loss from larger head size, thin skin, lack of subcutaneous pad of fat and limited ability of compensatory thermogenesis from brown fat. As such it is mandatory to design appropriate diagnostic, preventive and therapeutic strategies which can effectively protect pediatric population from the potential catastrophic complications associated with hypothermia during perioperative period. The current review aims to refresh the basic mechanism of hypothermia and discussion of evidence based management strategies to minimize the incidence of hypothermia in pediatric patients

Management of acute postoperative pain in pediatric patients

Pain is an unpleasant experience which can produce changes in all the systems of the body. Pain in children is not different from that in adults and can lead to similar detrimental effects on the body. The anticipation and effective treatment of pain in pediatric patients is thus, an essential component of care. A careful assessment of pediatric pain using age-specific pain scoring systems allows for exact quantification of pain. The use of various analgesics should be done early and in adequate doses for them to be effective. The use of multimodal approach with weaker analgesics along with regional blocks is an effective modality to control pain and prevent severe adverse effects associated with higher doses of potent analgesics. The advancement in the pharmacology of analgesics allows for their more widespread use with minimal side-effects. The use of patient or nurse controlled analgesia and continuous regional nerve blocks with the use of indwelling catheters can augment the pediatric pain management

Labour analgesia in pre-eclampsia: the current perspectives

Pre-eclampsia is a disease of pregnancy involving various systems with associated high blood pressure and other changes. The pathophysiology of this disease is not well known but the main pathological change is vasoconstriction in the vascular bed of the parturient with abnormalities in the uteroplacental circulation. A multi-disciplinary approach is essential for proper management of this disease. The provision of analgesia during labor significantly reduces the stress response and thus is helpful in reducing the elevated blood pressure and also exerts beneficial effects on uteroplacental perfusion. The neuraxial analgesia technique is considered to be the gold standard and has been found to be effective and safe in pre-eclamptic parturients. The use of lower concentrations of local anesthetic drugs in combination with opioids results in less motor blockade, lesser dose of drugs and lesser incidence of significant side-effects. The patient-controlled epidural analgesia technique is very beneficial with excellent maternal satisfaction. The concern of coagulation abnormalities associated with pre-eclampsia should be kept in mind with the institution of neuraxial techniques with careful monitoring of neurological status. The reduction in stress response with consequent reduction in blood pressure in pre-eclamptic parturient is highly desirable irrespective of the technique of analgesia used

Comparison of epidural butorphanol and fentanyl as adjuvants in the lower abdominal surgery: a randomized clinical study

Epidural opioids acting through the spinal cord receptors improve the quality and duration of analgesia along with dose-sparing effect with the local anesthetics. The present study compared the efficacy and safety profile of epidurally administered butorphanol and fentanyl combined with bupivacaine [B]. A total of 75 adult patients of either sex of American Society of Anesthesiologist physical status I and II, aged 20-60 years, undergoing lower abdominal under epidural anesthesia were enrolled into the study. Patients were randomly divided into three groups of 25 each: B, bupivacaine and butorphanol [BB] and bupivacaine + fentanyl [BF]. B [0.5%] 20 ml was administered epidurally in all the three groups with the addition of 1 mg butorphanol in BB group and 100 microg fentanyl in the BF group. The hemodynamic parameters as well as various block characteristics including onset, completion, level and duration of sensory analgesia as well as onset, completion and regression of motor block were observed and compared. Adverse events and post-operative visual analgesia scale scores were also noted and compared. Data was analyzed using ANOVA with post-hoc significance, Chi-square test and Fisher's exact test. Value of P < 0.05 was considered significant and P < 0.001 as highly significant. The demographic profile of patients was comparable in all the three groups. Onset and completion of sensory analgesia was earliest in BF group, followed by BB and B group. The duration of analgesia was significantly prolonged in BB group followed by BF as compared with group B. Addition of butorphanol and fentanyl to B had no effect on the time of onset, completion and regression of motor block. No serious cardio-respiratory side effects were observed in any group. Butorphanol and fentanyl as epidural adjuvants are equally safe and provide comparable stable hemodynamics, early onset and establishment of sensory anesthesia. Butorphanol provides a significantly prolonged post-operative analgesia.

Expanding giant right coronary artery aneurysm: an acute need for new management strategies

Angiography use has become increasingly common worldwide. Coronary artery aneurysm may be an incidental finding during angiography. Occasionally it might be symptomatic or may become symptomatic over the course of time. Rupture of aneurysm may lead to disastrous complications. Here we present a case in which aneurysm was asymptomatic but surgical intervention was done because of rapid increase in the size of aneurysm. This is to drive home the point that timely surgical intervention is instrumental in preventing complications associated with possible rupture of the aneurysm

Statins and succinylcholine interaction: a cause of concern for serious muscular damage in anesthesiology practice!

Statins are being extensively used in cardiac patient throughout the globe. Succinylcholine has been the mainstay of profound relaxation during induction and intubation of anesthesia for almost six decades now. The interactive properties of these drugs have been of major concern during routine anesthesiology practice in the last few years. However, no major research trial, prospective studies or meta-analysis are available, which can truly allay the fears of possible potential negative synergistic interactions between these two commonly used drugs. Whatever the evidence is available is hardly enough to support a positive outcome and the results have been drawn from observations of only few small studies. As a result, a continuous need among anesthesiologist fraternity is felt to arrive at a suitable inference, which can predict definite consequences of this synergistic interaction. The present article reviews some of the important observations of few handful studies which were carried out to observe any potential adverse interactions between succinylcholine and statins

Hypoglycaemia in anesthesiology practice: diagnostic, preventive, and management strategies

Diabetes mellitus has emerged as one of the fastest growing non communicable diseases worldwide. Management of diabetic patients during surgical and critically illness is of paramount challenge to anesthesiologist and intensivist. Among its major acute complications, hypoglycemia has been given lesser attention as compared to other major acute complications; diabetic ketoacidosis and hyperosmolar non ketotic coma. However, newer studies and literary evidence have established the serious concerns of morbidity and mortality, both long- and short-term, related to hypoglycemia. basis. Invariably, diabetic patients are encountered in our daily routine practice of anesthesia. During fasting status as well as the perioperative period, it is hypoglycemia that is of high concern to anesthesiologist. Management has to be based on clinical, pharmacological, social, and psychological basis, so as to completely prevent the complications arising from an acute episode of hypoglycemia. This review aims to highlight various aspects of hypoglycemia and its management both from endocrine and anesthesia perspective

Dose sparing of induction dose of propofol by fentanyl and butorphanol: a comparison based on entropy analysis

The induction dose of propofol is reduced with concomitant use of opioids as a result of a possible synergistic action. The present study compared the effect of fentanyl and two doses of butorphanol pre-treatment on the induction dose of propofol, with specific emphasis on entropy. Three groups of 40 patients each, of the American Society of Anaesthesiologistsphysical status I and II, were randomized to receive fentanyl 2 microg/kg [Group F], butorphanol 20 microg/kg [Group B 20] or 40 microg/kg [Group B 40] as pre-treatment. Five minutes later, the degree of sedation was assessed by the observer's assessment of alertness scale [OAA/S]. Induction of anesthesia was done with propofol [30 mg/10 s] till the loss of response to verbal commands. Thereafter, rocuronium 1 mg/kg was administered and endotracheal intubation was performed 2 min later. OAA/S, propofol induction dose, heart rate, blood pressure, oxygen saturation and entropy [response and state] were compared in the three groups. Data was analyzed using ANOVA test with posthoc significance, Kruskal-Wallis test, Chi-square test and Fischer exact test. A P<0.05 was considered as significant. The induction dose of propofol [mg/kg] was observed to be 1.1 +/- 0.50 in Group F, 1.05 +/- 0.35 in Group B 20 and 1.18 +/- 0.41 in Group B 40. Induction with propofol occurred at higher entropy values on pre-treatment with both fentanyl as well as butorphanol. Hemodynamic variables were comparable in all the three groups. Butorphanol 20 microg/kg and 40 microg/kg reduce the induction requirement of propofol, comparable to that of fentanyl 2 microg/kg, and confer hemodynamic stability at induction and intubation

Neuraxial opioids in geriatrics: a dose reduction study of local anesthetic with addition of sufentanil in lower limb surgery for elderly patients

Neuraxial anesthesia in the elderly is associated with exaggerated responses to conventional doses of local anesthetics, thereby increasing the incidence of hemodynamic complications. A double-blind prospective study was carried out in our institute with an aim to compare the hemodynamic stability and quality of the conventional dose of hyperbaric bupivacaine [LA] with low dose of LA and sufentanil in elderly patients scheduled for lower limb surgery, randomized to receive combined spinal epidural anesthesia. A total of 50 elderly patients of ASA grade I and II, divided randomly into groups I and II, of either sex undergoing lower limb surgery under combined spinal epidural anesthesia at our institute attached to a Government Medical College were enrolled for study. Group I received 2.5 ml of intrathecal hyperbaric bupivacaine [LA], while group II received 1.5 ml of intrathecal LA+0.1 ml sufentanil [5 ?g]. Both initial and postoperative subarachnoid block characteristics, hemodynamic and respiratory parameters, duration of analgesia, and side effects were observed and recorded. Statistical analysis was carried out using Chi-square and paired t test. Demographic profile was comparable in both groups. Group I had a greater incidence of hypotension and, consequently, higher use of vasopressors [P<0.05]. Onset of sensory analgesia, time to achieve peak sensory level, and recovery from motor blockade were significantly earlier in group II [P<0.05]. Postoperative consumption of LA through epidural route was significantly higher in group I [P<0.05]. The side effect profile was similar, except for a significantly higher incidence of shivering in group I [P<0.05]. The study established that the dose of a local anesthetic can be safely and significantly lowered by 40%, with addition of low-dose sufentanil, thereby avoiding the hemodynamic fluctuation and providing a stable perioperative and postoperative period in the geriatric population. In addition, duration of sensory analgesia is prolonged and postoperative requirement for the epidural top-up also decreases

Anesthesia implications in emergency oncologic surgery in a case of untreated Parkinsonism

Oncologic surgery has made tremendous advancements in the last two decades. The prognosis of once thought to be irreversible and incurable diseases has improved dramatically with these advancements, which have given a fresh lease of hope to the general population. But there are certain factors that are still unfavorable for achieving improved outcome of surgery in various cancers. The associated comorbid diseases do determine to a large extent the actual outcome of all the interventions to treat oncologic disease. The untreated coexisting disease makes the task of the attending anesthesiologist very challenging as numerous complications are anticipated, especially during emergency surgery. We are describing a case of a patient with endometrial carcinoma who presented with unstoppable bleeding per-vaginum and was suffering from Parkinson disease since 1.5 years, for which no treatment was ever sought. Vaginal hysterectomy was performed under graded epidural anesthesia; and after a smooth and uneventful postoperative period of 8 days, she was referred to radiotherapy unit for further management

Anesthetic considerations and difficult airway management in a case of Noonan syndrome

Noonan syndrome is a genetically transmitted autosomal dominant disorder characterized by various anatomic anomalies and pathophysiologic derangements. Anesthetic management in such cases poses a multitude of challenges, especially related to the airway management and maintenance of cardiovascular stability. We report a case of a 9-year-old male child weighing 24 kg, who was diagnosed as a case of Noonan syndrome and had undergone ligation of patent ductus arteriosus during early childhood. The child was operated on for release of bilateral neck bands under general anesthesia. The case report pertains to the successful airway and anesthetic management in the background of difficult airway and existence of various cardiac lesions