The Study of Postoperative Recall in Patients under Total Intravenous Anesthesia.

Background: The incidence of postoperative recall under total intravenous anesthesia (TIVA) is not yet fully established. Avoidance of inhalational agent is a known risk factor for awareness. In addition, lack of reliable technique to monitor drug concentration needed for adequate depth of anesthesia makes TIVA challenging. Hence, we intend to evaluate our standard anesthesia practice for postoperative recall. Methodology: This questionnaire-based observational study was done over the period of 2 years. We enrolled 1080 adult (American Society of Anesthesiologists physical status Class I or II) patients undergoing TIVA for Endoscopic retrograde cholangiopancreatography (ERCP). All patients received fentanyl, midazolam and propofol-based anesthesia. Manual boluses of propofol were given to achieve adequate sedation. (Ramsay sedation scale of 5) in accordance with clinical signs as judged by the primary anesthesiologist. Postoperatively within 12-24 h, patients were assessed for recall using Brice questionnaire. Primary outcome was number of patients reporting postoperative recall in the Brice interview. Secondary outcome was the incidence of dreaming. Results: On postoperative interview, none of the patients reported awareness. 12.5% of patients had dreams which were pleasant. None of the dreams was unpleasant. The worst thing about surgery was pain. Conclusion: Our study suggests that if adequate doses of propofol are adhered to and necessary action is taken against responses indicating wakefulness, postoperative recall under TIVA is an uncommon occurrence.

Fascia iliaca block vs intravenous fentanyl as an analgesic technique before positioning for spinal anesthesia in patients undergoing surgery for femur fractures-a randomized trial.

STUDY OBJECTIVE: Pain arising from femur fractures is of severe nature. Surgery for fixation of femoral fractures may be done under spinal anesthesia. We conducted this study to compare the analgesic efficacy of fascia iliaca compartment block (FICB) and intravenous fentanyl (IVF) before positioning for spinal anesthesia. DESIGN: Randomized controlled trial. SETTING: Operating room. PATIENTS AND INTERVENTIONS: Sixty patients aged 25 to 75 years, with American Society of Anesthesiologists status I to III, undergoing surgery for femur fracture were chosen for the study and randomized into 2 groups. Patients in group FICB received the block with 30 mL of 0.375% ropivacaine 15 minutes before the subarachnoid block. Patients in group IVF received intravenous fentanyl at 0.5 µg/kg body weight repeated up to a maximum of 3 doses. Spinal was administered using 12 to 15 mg of 0.5% hyperbaric bupivacaine with glucose 80 mg/mL in patients of both groups. MEASUREMENTS: Preprocedural and postprocedural parameters such as visual analog scale (VAS) scores, sitting angle, quality of positioning, and time to perform the spinal were recorded. Patients were also assessed in the first 24 hours for analgesic requests. MAIN RESULTS: Preprocedural VAS scores were similar in both groups. The "VAS after" was 24.72±15.70 mm in group FICB vs 61.22±18.18 mm in group IVF (P=.01). The drop in VAS scores was significantly more in the FICB group. Sitting angle improved significantly in the FICB group. (56.17°±16.54° vs 21.38°±23.90°; P=.01). Patients in group FICB also needed less time for spinal and had better quality of positioning. Postoperative analgesic requirement was lesser in group FICB. CONCLUSION: Fascia iliaca block offers superior analgesia compared to IVF in patients with femur fracture before positioning for spinal anesthesia.

BIS Targeted Propofol Sparing Effects of Dexmedetomidine Versus Ketamine in Outpatient ERCP: A Prospective Randomised Controlled Trial.

BACKGROUND: Endoscopic Retrograde Cholangio Pancreatography (ERCP) is routinely performed under propofol sedation. Adjuvant drugs have improved the quality of propofol sedation while minimizing complications. The aim of the study was to compare the propofol consumption, recovery and hemodynamic profiles of dexmedetomidine versus ketamine against a placebo control with BIS targeted in the sedative range for outpatient ERCP procedures. MATERIALS AND METHODS: The study comprised of 72 patients undergoing ERCP, who were randomly allocated into one of the 3 groups: Group Dexmedetomidine (n =24) receiving a bolus and infusion of dexmedetomidine (1µg/kg and 0.5µg/kg/hr); Group Ketamine (n = 24) receiving a bolus and infusion of ketamine (0.25mg/kg and 5µg/kg/min) and Group Control (n =24) receiving saline placebo as a bolus and infusion with variable propofol boluses administered in all groups targeting BiSpectral Index between 60-70. RESULTS: The total propofol consumption was significantly lower in both Dexmedetomidine (162.5 ± 71.7 mg ) and Ketamine groups (158.3 ± 66.89 mg) when compared with Control group (255.83 ± 114.12 mg)(p=0.001) .Time taken (minutes) to achieve Modified Aldrette Score (MAS) >9 and Observer Assessment of Alertness and Sedation (OAAS) score >4 was significantly prolonged in Dexmedetomidine group (MAS 16.6 ± 3.18 and OAAS 16.67 ± 2.82) compared to Ketamine (MAS 10 ± 4.17 and OAAS 8.75 ± 3.68) and Control (MAS 7.5 ± 3.29 and OAAS 6.88 ± 2.47) (p<0.001). Hemodynamic profiles were comparable although patients in dexmedetomidine had a statistically significant lower heart rate (p<0.001) although without clinical significance. CONCLUSION: Low dose ketamine with background propofol boluses resulted in lesser propofol consumption, with earlier recovery and favourable hemodynamics when compared with Dexmedetomidine and control group in outpatient ERCP.

Light at a tunnel's end: The lightwand as a rapid tracheal location aid when encountering false passage during tracheostomy.

False passage and loss of airway during tracheostomy are not uncommon, especially in patients with short and thick necks. Distorted neck anatomy following either repeated insertion attempts or due to underlying malignancy may make it very difficult to locate the trachea even while attempting open/surgical tracheostomy, despite good exposure of the neck in such situations. The lightwand is not an ideal device for tracheal intubation in such patients. However, it can be useful in these patients while performing open tracheostomy. Passing the lightwand through the orotracheal tube can aid in rapid identification of the trachea in such situations and may help reduce the occurrence of complications subsequent to repeated false passage. We report a series of four such cases where use of lightwand aided in rapidly locating the trachea during tracheostomy complicated by distorted anatomy.