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Background: Awake fiberoptic intubation (AFOI) is the procedure of choice for securing the airway in patients with a difficult airway when undergoing surgeries under general anesthesia. An ideal drug would not only provide conscious sedation but also maintain spontaneous ventilation, smooth intubation conditions, and stable hemodynamics. We compared the effects of dexmedetomidine alone and dexmedetomidine in combination with fentanyl at a dose lower than the standard dose for achieving conscious sedation during AFOI in difficult airway patients undergoing oral cancer and dental surgeries. Methods: We included 68 adult patients undergoing AFOI. The patients were randomized in two groups, wherein Group D received intravenous dexmedetomidine 1 µg/kg and Group DF received dexmedetomidine 0.5 µg/kg and fentanyl 1 µg/kg. The outcomes measured were airway obstruction score, intubation scores, fiberoptic intubation comfort score, sedation score, and hemodynamic variables. Results: Low-dose dexmedetomidine with fentanyl showed similar results as those with the standard dose of dexmedetomidine in terms of airway obstruction, vocal cord movement, degree of cough, degree of limb movements, and intubation comfort. However, the sedation achieved and incidence of hypotension and bradycardia were higher in Group D than in Group DF. Conclusions: A low dose of dexmedetomidine-fentanyl provides satisfactory intubation conditions as those with a standard dose of dexmedetomidine in AFOI, thereby avoiding bradycardia, hypotension, and sedation.
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Background: One of the most feared symptoms of any disease is PAIN. It is a complex phenomenal experience, especially in children. Various methods and medications have been administered through different routes. Regional anesthesia produces marvelous postoperative analgesia and cessation of stress response in infants and children. Caudal epidural analgesia is the most acceptable and popular method of providing intra- and postoperative analgesia for abdominal, perineal, and lower limb surgeries in children. The use of preservative-free morphine as an adjunct to ropivacaine increases the quality and duration of analgesia despite the various side effects. Various articles use various doses of morphine as an adjuvant in caudal epidural analgesia. Hence, we conducted the study to compare the two dosages of morphine that is 20 µg.kg-1 and 30 µg.kg-1 of caudal epidural morphine for infraumblical surgeries with regard to its efficacy and safety and side effect profiles. Materials and Methods: The study is a prospective, randomized, double-blinded study. Sixty patients were divided into two groups. Group A: 20 µg.kg-1 of morphine was added to 0.2% ropivacaine 1 mL.kg-1 and the solution was made. Group B: 30 µg.kg-1 of morphine was added to 1 mL.kg-1 of 0.2% ropivacaine. Heart rate, systolic blood pressure, diastolic blood pressure, SPO2, pain score, and sedation score were recorded immediately, after 15 min, 30 min, 45 min, 1 h, 2 h, 4 h, 8 h, 12 h, 16 h, 18 h, and 24 h were recorded. Results: The mean duration of analgesia is similar in both groups (P = 0.011). The mean duration was 20.517 ± 1.9143 h in Group A and 22.233 ± 1.6853 h in Group B. Children with the requirement of one dose of rescue analgesia in Group A was 83.3% which was higher than Group B being 66.7%. Children with no analgesic requirement were 16.7% in Group A and 33.3% in Group B. The incidence of side effects was more in Group B (8 [26.7%] children with nausea and vomiting; 1 [3.3%] children with urinary retention) than in Group A (2 [6.6%] children with nausea and vomiting. Conclusion: From the above observations, it can be concluded that morphine of less dosage (20 µg.kg-1) when added to 0.2% ropivacaine for the caudal epidural block has better efficacy than morphine of higher dosage (30 µg.kg-1) as the duration of analgesia is similar with decreased incidence of side effects.
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BACKGROUND: Fascia iliaca block (FIB) is an established procedure for postoperative pain relief in femur fracture surgeries. Dexmedetomidine was found to be a useful additive to local anesthetics (LA) for peripheral nerve blocks resulting in a prolonged anesthetic effect. We evaluated the impact of the addition of dexmedetomidine to an equal concentration of levobupivacaine and ropivacaine for FIB. Methods: The present study is a double-blind, randomized trial conducted on 60 patients in the age group 18-70 years. The patients were divided into two groups: Group LD received 30 ml of an LA solution (29.5 ml 0.25% levobupivacaine and 0.5 ml dexmedetomidine 50 µg), and group RD received 30 ml of another LA solution (29.5 ml 0.25% ropivacaine and 0.5 ml dexmedetomidine 50 µg). The outcomes observed were the duration of analgesia (DOA) and total analgesic requirement (TAR). RESULTS: The DOA was found to be slightly longer in group LD (955.3 ± 114.5 minutes) than in group RD patients (894.6 ± 91.3) with p = 0.027. The TAR was found to be statistically different though clinically irrelevant (group LD: 112 mg; IQR: 105-122 vs. Group RD: 115 mg; IQR: 104-118, p = 0.034, where IQR stands for interquartile range). There were no signs of neurotoxicity in any of the participating patients. CONCLUSION: Addition of 50 µg dexmedetomidine to 0.25% levobupivacaine extends DOA slightly as compared to when dexmedetomidine is added to 0.25% ropivacaine. However, TAR remains clinically the same for both cases in fascia iliaca block.
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BACKGROUND AND AIMS: Central line associated bloodstream infections (CLABSI) have a higher incidence in the intensive care units of developing countries. MATERIALS AND METHODS: The baseline CLABSI rate in intensive care unit (ICU) was evaluated for 6 months. An educational program for nurses on basic hand hygiene steps was conducted. Objective assessment tests were done to assess their knowledge and percentage of non-compliance with hand hygiene practice. CLABSI rate over the post-intervention 6 month period was assessed. RESULTS: Thirty-four nurses were enrolled. The pre-intervention CLABSI rate was 12.5 per 1000 catheter days, pretest score 15.9 +/- 3.35 and 53.4% opportunities for hand hygiene were missed. Post workshop, there was significant (p=0.02) decrease in CLABSI rate i.e. 8.6, improvement in test score 17.76 +/- 2.1 (p=0.011) and missed opportunities decreased to 33.75%. 6 months post intervention, percentage of noncompliance with hand hygiene practice were 51.75% and test score was 17 ± 2. DISCUSSION: The effectiveness of educational program on hand hygiene compliance was reflected in the improvement of posttest score, reduced number of missed opportunities and reduction of CLABSI rates in ICU. The posttest scores and hand hygiene compliance, however, decreased 6 months post-intervention necessitating repeated feedbacks and reminders. CONCLUSION: Educational interventions on hand hygiene can have a significant impact in CLABSI control particularly in ICUs with a high infection rate and resource constraints. HOW TO CITE THIS ARTICLE: Acharya Ranjita, Mishra SB, Ipsita S, Azim A. Impact of Nursing Education on CLABSI Rates: An Experience from a Tertiary Care Hospital in Eastern India. Indian J Crit Care Med 2019;23(7):316-319.
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BACKGROUND: General anesthesia is preferred for clavicular surgeries. With the advent of ultrasound-guided technology, interscalene brachial plexus block with superficial cervical nerve block has become a new option for providing intraoperative anesthesia and postoperative analgesia for surgeries of the clavicle. AIMS AND OBJECTIVES: The present study compares the ultrasound-guided interscalene brachial plexus nerve block combined with superficial cervical nerve block to general anesthesia in clavicular surgery. SETTINGS AND DESIGN: This study was a randomized controlled trial in a tertiary care setting. MATERIALS AND METHODS: A total of 60 patients between 18 and 60 years who were scheduled for clavicular surgeries were randomly and equally divided into Group B and Group G. Group B received ultrasound-guided interscalene brachial plexus block with superficial cervical nerve block. Group G received general anesthesia. Time duration between start of anesthesia to the incision time, intraoperative vitals, and time spent in postanesthesia care unit, postoperative pain scores, postoperative analgesic consumption, and complications were noted and compared. STATISTICAL ANALYSIS: Statistical analyses were done using SPSS software 20.0. Normality tests were applied, and accordingly, parametric and nonparametric tests were used to calculate the results. RESULTS: The demographic data were comparable in both the groups. Time duration between start of anesthesia to the incision time was significantly more in Group B than in Group G. The time spent in postanesthesia care unit and postoperative pain scores were significantly more in Group G than Group B. Total postoperative opioid consumption was significantly less in Group B than in Group G. CONCLUSION: Ultrasound-guided interscalene brachial plexus block combined with superficial cervical nerve block is a safe and effective mode of anesthesia in comparison to general anesthesia for clavicle surgeries.
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BACKGROUND: To compare the effects of adding two different doses of dexamethasone on the duration and quality of the fascia iliaca block in patients undergoing proximal femoral fracture surgery. METHODS: A total of 60 patients (age 18-70 years) undergoing proximal femoral nailing surgery under spinal anesthesia were given fascia iliaca block after random assignment to one of the two groups: Group H received an injection of levobupivacaine (0.5%) 28 ml with 2 ml (8 mg) dexamethasone, and Group L received an injection of levobupivacaine (0.5%) 28 ml with dexamethasone 1 ml (4 mg) with 1 ml normal saline. Assessment of the duration of analgesia and the total tramadol requirement over 48 hours were noted after a successful block. RESULTS: The duration of analgesia was found to be significantly longer in Group H (17.02 ± 0.45 h) than in the Group L patients (14.29 ± 0.45 h) with a p-value of 0.000. Postoperative analgesic requirement (amount of tramadol in mg) was significantly higher in Group L (Q2: 200.0; IQR: 100.0, 200.0) as compared to Group H (Q2: 100.0; IQR: 100.0, 200.0) with a p-value of 0.034. No patient showed any sign of neurotoxicity. CONCLUSIONS: Dexamethasone, in a dose of 8 mg, is superior to 4 mg when used as an adjuvant with levobupivacaine in the FIB. Though both prolonged analgesia and were effective in reducing oral/intravenous analgesics, 8 mg dexamethasone can be recommended as a more efficacious adjuvant to local anesthetics in the FIB.
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BACKGROUND: Transversus abdominis plane (TAP) block in cesarean section is carried out by local anesthetics such as bupivacaine or ropivacaine with a limited duration of analgesia. The addition of adjuvants such as clonidine and dexmedetomidine has increased the duration of postoperative analgesia. AIMS SETTINGS AND DESIGN: The aim of this study was to compare the duration of postoperative analgesia between clonidine and levobupivacaine (0.25%) versus levobupivacaine (0.25%) alone in the bilateral TAP block after lower segment cesarean section (LSCS). MATERIALS AND METHODS: In this prospective randomized double-blind interventional study, 100 parturients undergoing elective LSCS were included in the study. Patients were randomly divided to receive either 20-ml levobupivacaine 0.25% (Group A; n = 50) or 20-mL levobupivacaine (0.25%) +1-µg/kg clonidine bilaterally (Group B; n = 50) in TAP block in a double-blind fashion. The total duration of analgesia, patient satisfaction score, postoperative visual analog scale score, total requirement of analgesics in the first 24 h, and the side effects of clonidine were observed. STATISTICAL ANALYSIS: Statistical tests were conducted using SPSS. P < 0.05 was considered as statistically significant. RESULTS: A total of 92 patients were analyzed. Duration of analgesia was significantly longer in Group B (17.94 ± 0.76 h) compared to Group A (7.16 ± 0.41 h) (P < 0.001). Mean consumption of tramadol was 197.77 ± 14.90 mg and 8.889 ± 28.77 mg in Groups A and B (P < 0.001), respectively. All patients in Group B were extremely satisfied while those in Group A were satisfied (P < 0.01). None of the patients experienced hypotension or bradycardia. CONCLUSION: The addition of clonidine 1 µg/kg to 20-ml levobupivacaine 0.25% in TAP block bilaterally for cesarean section significantly increases the duration of postoperative analgesia, decreases postoperative rescue analgesic requirement, and increases maternal comfort compared to 20 ml of levobupivacaine 0.25% alone.
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Rosai-Dorfman's disease (RDD) is a rare multisystemic histiocytic disorder, commonly presenting as cervical lymphadenopathy in a young male. Its extranodal form is very unusual. We report a case of extranodal RDD presenting as a large vallecular mass. Management of an airway mass is always a challenge to the anesthesiologist. This problem is accentuated when the mass is due to RDD, as RDD can involve multiple system of the body such as central nervous system, upper respiratory tract, orbit and eyelid, gastrointestinal tract, and skin. Autoimmune phenomenon though rare is also an important concern. Individualized plan based upon thorough evaluation and anticipation is the key for better outcome.
