Comparative Evaluation of Nalbuphine and Fentanyl for Attenuation of Pressor Response to Laryngoscopy and Tracheal Intubation in Laparoscopic Cholecystectomy.

Background In this study, our primary aim was to compare the efficacy of fentanyl and nalbuphine in attenuating the pressor response to laryngoscopy and tracheal intubation in patients undergoing laparoscopic cholecystectomy under general anesthesia. The secondary aim was to observe hemodynamic response to pneumoperitoneum and to study the level of sedation using the Richmond Agitation-Sedation Scale (RASS). Methodology A total of 180 patients belonging to the American Society of Anesthesiologist Physical Status class I/II scheduled to undergo elective laparoscopic cholecystectomy under general anesthesia were divided into two groups of 90 each. group A received intravenous nalbuphine 0.2 mg/kg and group B received intravenous fentanyl 2 µg/kg, five minutes before induction of anesthesia. Technique of anesthesia was standardized for all patients in the study. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded before giving the study drug; before induction; immediately after intubation; at one, three, and five minutes after intubation; before creating pneumoperitoneum; 15 minutes after creating pneumoperitoneum; and five minutes after release of pneumoperitoneum. Preoperative and postoperative sedation scoring was done using RASS. Results Immediately after intubation, HR was significantly higher in group A (p = 0.016). Both groups showed a rise in SBP immediately after intubation. Group A showed a significantly higher SBP in comparison to group B (135.97 ± 13.02 vs. 130.04 ± 13.33; p = 0.003). The DBP and MAP showed a similar trend. At one, three, and five minutes after intubation, HR, SBP, DBP, and MAP were similar between the groups. Post-extubation sedation score was significantly higher in group A (p < 0.0001). Conclusions We found that fentanyl was more effective than nalbuphine in attenuating the pressor response to laryngoscopy and tracheal intubation in patients undergoing laparoscopic cholecystectomy under general anesthesia. There was no significant difference observed between nalbuphine and fentanyl in the hemodynamic response to pneumoperitoneum. The depth of sedation post-extubation was significantly greater with nalbuphine.

The effects of intravenous dexmedetomidine premedication on intraocular pressure and pressor response to laryngoscopy and intubation.

BACKGROUND AND AIMS: Penetrating eye injuries are a challenge for the anesthesiologists in emergency due to increase in intraocular pressure (IOP). The aim of this study was to evaluate the effects of intravenous dexmedetomidine premedication on changes in IOP and hemodynamic response following laryngoscopy and tracheal intubation. MATERIAL AND METHODS: Hundred patients aged 18-60 years undergoing elective nonophthalmic surgery were divided into two groups of 50 each. Group D received a bolus dose of dexmedetomidine (0.4 µg/kg) diluted to 20 ml normal saline and Group C received normal saline (0.4 ml/kg) over 10 min as premedication. Heart rate (HR), systolic blood pressure (SBP) and IOP were measured and recorded before premedication (T1), 5 and 10 m after premedication (T2, T3), immediately after induction, intubation and then 1, 3, 5 min after intubation (T4, 5, 6, 7, 8). RESULTS: HR was comparable in both groups at preoperative level, but it was significantly low in the drug group when compared with the control group at T4-T8 (P = 0.034, P < 0.001, 0.001, 0.036 and 0.001, respectively). The SBP was comparable in both the groups at baseline and till before induction. At T4-T8 there was a fall in SBP in Group D compared to the Group C (P = 0.045, P = 0.007, 0.001, 0.001 and 0.001, respectively). The baseline IOP was comparable in both the groups (P = NS). There was a significant fall in the IOP in Group D, 5 min after the drug infusion compared to Group C, which was sustained till 5 min after intubation (T8) (P < 0.001 at all intervals). CONCLUSION: Dexmedetomidine premedication in the dose of 0.4 µg/kg lowers the IOP and attenuates the pressor response to laryngoscopy and intubation.

Urinothorax: A rare cause of severe respiratory distress.

A case of massive right pleural effusion in a postoperative patient of percutaneous nephrolithotomy leading to severe respiratory distress is reported. A high degree of clinical suspicion and prompt intervention by insertion of an intercostal drainage tube prevented the patient from going in to respiratory failure. The development of arrhythmias confused the picture increasing the morbidity of the patient. However, the patient was managed in an intensive care unit with intercostal chest tube insertion and antiarrhythmic agents. After correction of the specific cause of the effusion the intercostal tube was removed on the 4(th) day without further recurrence of the effusion.

Prallethrin poisoning: A diagnostic dilemma.

Pyrethroid insecticides are very widely used in agriculture and household due to their high effectiveness and low toxicity in humans. Despite their extensive worldwide use, there are a few reports of human pyrethroid poisoning. The poisoning has a varied presentation and its symptoms overlap with those of other compounds, which can lead to misdiagnosis. We present a case of poisoning with prallethrin, a pyrethroid compound, commonly available as All-Out.

Tuberculosis and anaesthesia.

Anaesthesiologists and other healthcare workers have been at risk for nosocomial infection with tuberculosis for many years, however the advent of effective infection control techniques and the development of antibiotics for Mycobacterium tuberculosis have decreased the risk of nosocomial infection. The risk of transmission of tuberculosis from patients to healthcare workers is a neglected problem in many developing and underdeveloped countries as they lack the resources to prevent nosocomial transmission of tuberculosis. Patients with active tuberculosis can present with problems related to tuberculosis or unrelated problems like trauma to anaesthetist for various surgeries. An attempt has been made to highlight the precautions to be taken and the risk that the anaesthesiologists are at while getting these patients operated. A detailed pre-operative examination and investigation is essential. The various drug interactions, side-effects of antituberculous drugs should be considered pre-operatively. The patients coinfected with HIV and tuberculosis have a higher risk of developing tuberculosis should be kept in mind.

Fibreoptic bronchoscopy without sedation: Is transcricoid injection better than the "spray as you go" technique?

AIM: The aim of the study was to compare transcricoid injection with spray as you go technique for diagnostic fibreoptic bronchoscopy, to perform the procedure without sedation and to record any complication or side effects. METHODS: Sixty patients belonging to the age group 20-70 years, undergoing diagnostic bronchoscopy over a period of 6 months, were randomly selected and divided into two groups alternatively to receive 3 ml of 4% lignocaine by a single transcricoid puncture (group I) or 2 ml of 4% lignocaine instilled through the bronchoscope on to the vocal cords and further 1 ml of 2% lignocaine into each main bronchus (group II). Additional dose of lignocaine as required was given in both the groups. All patients were given intramuscular atropine 0.6 mg, 20 min before the procedure. Nebulisation with 3 ml of 4% lignocaine was given to all patients. The time from nasal insertion of the bronchoscope to reach the carina was recorded, and the total dose of lignocaine required in both the groups was calculated and compared. The cough episodes during the procedure, systolic blood pressure, and pulse rate were compared before the procedure and 5 min after the procedure in both the groups. A0-10 visual analogue scale (VAS) was used to assess discomfort 30 min after the procedure. RESULTS: The time to reach carina was more in group II (P<0.02), and cough episodes were also more in group II (P<0.05) than in group I. The vitals before the procedure were comparable in both the groups, but 5 min after the procedure the vitals were more stable in group I than in group II, and the total dose of lignocaine required in group II was more than in group I (P<0.001). However, the VAS score was comparable in both the groups. CONCLUSION: Transcricoid puncture for diagnostic bronchoscopies without sedation was associated with no complication and discomfort and required lesser dose of local anaesthetic with more stable vitals and good conditions for bronchoscopists.

Use of transcutaneous electrical nerve stimulation as an adjunctive to epidural analgesia in the management of acute thoracotomy pain.

The present randomized study was conducted in our institute of pulmonary medicine and tuberculosis over a period of 1 year. This study aimed to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) as an adjunctive to thoracic epidural analgesia for the treatment of postoperative pain in patients who underwent posterolateral thoracotomy for decortication of lung. Sixty patients in the age group 15-40 years scheduled to undergo elective posterolateral thoracotomy were divided into two groups of 30 each. Patients were alternatively assigned to one of the groups. In group I, only thoracic epidural analgesia with local anaesthetics was given at regular intervals; however, an identical apparatus which did not deliver an electric current was applied to the control (i.e. group I) patients. While in group II, TENS was started immediately in the recovery period in addition to the epidural analgesia. A 0-10 visual analog scale (VAS) was used to assess pain at regular intervals. The haemodynamics were also studied at regular intervals of 2 h for the first 10 h after the surgery. When the VAS score was more than three, intramuscular analgesia with diclofenac sodium was given. The VAS score and the systolic blood pressure were comparable in the immediate postoperative period (P = NS) but the VAS score was significantly less in group II at 2, 4, 6, 8 h (P < 0.01, P < 0.05, P < 0.05, P < 0.05, respectively), and at 10 h the P value was not significant. Similarly, the systolic blood pressure was significantly less in group II at 2, 4, 6 h after surgery, that is P < 0.02, P < 0.01, P < 0.01, respectively, but at 8 and 10 h the pressures were comparable in both the groups. Adding TENS to epidural analgesia led to a significant reduction in pain with no sequelae. The haemodynamics were significantly stable in group II compared to group I. TENS is a valuable strategy to alleviate postoperative pain following thoracic surgery with no side effects and with a good haemodynamic stability; however, the effects are short lasting.