A Comparative Study of Bilateral Erector Spinae Block Versus Intravenous Dexmedetomidine for Perioperative Pain Management in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting - A Single-Blind Randomized Controlled Trial.

OBJECTIVE: Regional analgesia, along with general anesthesia, reduce postoperative pain. In this study, the authors compared the erector spinae plane (ESP) block having dexmedetomidine as an adjuvant with conventional pain management along with intravenous dexmedetomidine. DESIGN: Prospective randomized single-blinded trial. SETTING: Tertiary care teaching hospital. PARTICIPANTS: All of the patients scheduled for elective off-pump coronary artery bypass grafting with an ejection fraction of >45%. INTERVENTIONS: After obtaining institutional ethical committee approval, 130 patients were randomized into Group E and Group D. Group E patients received ESP block bilaterally with 25 mL of bupivacaine plus 0.5 µg/kg of dexmedetomidine. The patients in Group D received conventional intravenous analgesia, as well as a 0.7 µg/kg of dexmedetomidine bolus, followed by a 0.3 µg/kg dexmedetomidine infusion during surgery and continued postoperatively for 24 hours. Group E patients received 8 mL/h of bupivacaine infusion bilaterally for 24 hours. MEASUREMENTS: The primary outcome assessed was pain scores in the postoperative period. The secondary outcomes assessed were postoperative rescue analgesic consumption, time to first rescue analgesia, intraoperative fentanyl consumption, duration of mechanical ventilation, and duration of intensive care unit (ICU) stay. RESULTS: Both groups were comparable in demographic characteristics. The postoperative pain scores from 4 hours to 12 hours were lower in Group E compared with Group D. The pain scores at 24 hours were not significantly different between groups. Postoperative fentanyl consumption in Group E (99.23 ± 50.19 µg) was significantly lower than in Group D (181.15 ± 82.92 µg), with a p value of 0.001. Time to first rescue analgesia was significantly longer in Group E, with a median score of 8 hours when compared with that of 4 hours in Group D, with a p value of 0.01. Intraoperative fentanyl consumption was significantly lower in Group E (392.15 ± 55.36 µg) compared with Group D (604.00 ± 131.87 µg; p = 0.001). There were no significant differences in the duration of mechanical ventilation in both groups. Duration of ICU stay was significantly lower in Group E (51.95 ± 8.54 hours) when compared with Group D (59.06 ± 8.68 hours) (p = 0.001). CONCLUSIONS: Erector spinae fascial plane blocks appeared to reduce postoperative pain scores in off-pump coronary artery bypass graft patients. Furthermore, ESP block was beneficial in terms of less intraoperative and postoperative opioid consumption, longer time to first rescue analgesia, and shorter ICU stay.

Effects of regional anaesthesia on mortality in patients undergoing lower extremity amputation: A retrospective pooled analysis.

Background and Aims: Lower extremity amputation (LEA) is a commonly performed surgery and is associated with significant mortality and morbidity. This review compares the impact of anaesthetic technique on 30-day mortality and other perioperative outcomes in patients undergoing LEA. Methods: A systematic search of databases including PubMed, Embase, Scopus and Cochrane Central Register of Controlled Trials, from January 2010 to March 2021, was performed. Studies were eligible if they compared 30-day mortality following either general anaesthesia (GA) or regional anaesthesia (RA), in adult patients undergoing LEA. Results: Ten retrospective observational studies were identified. Four of these studies utilised a propensity-score matching technique. Based on these four studies, RA when compared to GA, is not associated with a reduction in the 30-day mortality (Odds ratio 0.83, 95% confidence interval (CI): 0.65, 1.05, I2 20%, P = 0.12). Also there is a very low level of evidence that RA may result in a decrease in the hospital length-of-stay and intensive care unit admissions of patients undergoing LEA. Conclusion: RA does not decrease the 30-day postoperative mortality in patients undergoing LEA when compared to GA.

Is hypotensive anaesthesia guided by invasive intraarterial monitoring required for orthognathic surgery? - A retrospective review of anaesthetic practice and intraoperative blood loss in orthognathic surgery in a tertiary hospital.

BACKGROUND AND AIMS: Orthognathic surgeries for maxillofacial deformities are commonly performed globally and are associated with significant blood loss. This can distort the surgical field and necessitate blood transfusion with its concomitant risks. We aimed to review if invasive intraarterial (IA) line monitoring and/or hypotensive anaesthesia is required for orthognathic surgeries, and their effects on intraoperative blood loss and transfusion requirements. METHODS: This was a retrospective observational study conducted in patients admitted for orthognathic surgeries in a public tertiary hospital. Anaesthetic techniques and intraoperative haemodynamics were studied for their effects on intraoperative blood loss. RESULTS: The data from 269 patients who underwent orthognathic-bimaxillary surgeries was analysed. Inhalational anaesthetic combined with remifentanil was administered for 86.6%, total intravenous anesthesia to 11.2% patients, while the rest received inhalational anaesthesia. Hypotensive anaesthesia was achieved in 48 subjects (17.8%) and associated with shorter duration of surgery (349 vs 378 min, P = 0.02) and a trend towards lower blood loss (874 mL vs 1000 mL, P = 0.058) but higher transfusion requirement (81.3% vs 58.8%, P = 0.004). An IA line was used in 119 patients (44.2%) and was not associated with a higher probability of achieving hypotensive anaesthesia (19.3% vs 16.7%, P = 0.06). However, less blood loss (911 vs 1029 mL, P = 0.05) occurred compared to noninvasive blood pressure monitoring. CONCLUSION: Invasive blood pressure monitoring is as effective as noninvasive methods to achieve hypotensive anaesthesia. It does not aid in achieving lower target blood pressure. There is a lack of association between a reduction in blood loss and higher blood transfusion during hypotensive anaesthesiaand thiswill require further evaluation.

Comparison of Ropivacaine and Levobupivacaine in Supraclavicular Brachial Plexus Blocks-A Double Blinded Randomized Control Study.

BACKGROUND: Brachial plexus anaesthesia has been an indispensable tool in the anaesthesiologist's armamentarium. Clinical studies have shown that levobupivacaine and ropivacaine have fewer adverse effects on the cardiovascular and central nervous system making them more advantageous in regional anaesthesia techniques. Less information is available regarding their comparable clinical data. Only a few studies have compared levobupivacaine and ropivacaine for brachial plexus blocks; hence, this study was aimed to compare the analgesic effectiveness and nerve block characteristics of ropivacaine and levobupivacaine in supraclavicular brachial plexus blocks in upper limb surgeries. METHODS: Patients with American Society of Anaesthesiologists physical status I or II coming for elective upper limb surgeries were included in the study. Total numbers of 62 patients were randomly allocated into two groups, group A and group B. Group A received 25mL of 0.75% ropivacaine, and group B received 25mL of 0.5% levobupivacaine. The duration of analgesia, onset of block, duration of sensory, and motor blockade were studied and compared. RESULTS: The mean duration of analgesia in group ropivacaine was 8.33 hours and in group levobupivacaine was 10.23 hours which was statistically significant. Ropivacaine had a faster sensory onset compared to levobupivacaine (5.22 vs. 6.88 minutes). The duration of sensory and motor blockade was longer with levobupivacaine than ropivacaine (sensory-8.64 vs. 10.29 hours, motor-8.32 vs. 9.8 hours). CONCLUSION: Levobupivacaine had longer duration of analgesia. The sensory and motor blockade was also longer with levobupivacaine.

A survey of practices during cardiopulmonary bypass in India: An Indian association of cardiovascular and thoracic anesthesiologist endeavor.

Context: Cardiac anesthesiologists play a key role during the conduct of cardiopulmonary bypass (CPB). There are variations in the practice of CPB among extracorporeal technologists in India. Aims: The aim of this survey is to gather information on variations during the conduct of CPB in India. Settings and Design: This was an online conducted survey by Indian College of Cardiac Anaesthesia, which is the research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists. Subjects and Methods: Senior consultants heading cardiac anesthesia departments in both teaching and nonteaching centers (performing at least 15 cases a month) were contacted using an online questionnaire fielded using SurveyMonkey™ software. There were 33 questions focusing on institute information, perfusion practices, blood conservation on CPB; monitoring and anesthesia practices. Results: The response rate was 74.2% (187/252). Fifty-one (26%) centers were teaching centers; 18% centers performed more than 1000 cases annually. Crystalloid solution was the most common priming solution used. Twenty-three percent centers used corticosteroids routinely; methylprednisone was the most commonly used agent. The cardioplegia solution used by most responders was the one available commercially containing high potassium St. Thomas solution (55%), followed by Del Nido cardioplegia (33%). Majority of the responders used nasopharyngeal site to monitor intraoperative patient temperature. Antifibrinolytics were commonly used only in patients who were at high risk for bleeding by 51% of responders, while yet, another 39% used them routinely, and 11% never did. About 59% of the centers insist on only fresh blood (<7 days old) when blood transfusion was indicated. The facility to use vaporizer on CPB was available in 62% of the centers. All the teaching centers or high volume centers in India had access to transesophageal echocardiography probe and echo machine, with 51% using them routinely and 38% using them at least sometimes. Conclusions: There is a wide heterogeneity in CPB management protocols among various Indian cardiac surgery centers. The survey suggests that adherence to evidence-based and internationally accepted practices appears to be more prevalent in centers that have ongoing teaching programs and/or have high volumes, strengthening the need to devise guidelines by appropriate body to help bring in uniformity in CPB management to ensure patient safety and high quality of clinical care for best outcomes.

Association between frailty, cerebral oxygenation and adverse post-operative outcomes in elderly patients undergoing non-cardiac surgery: An observational pilot study.

BACKGROUND AND AIMS: Although both frailty and low cerebral oxygen saturation increase the risk of post-operative complications, their relationship is yet to be investigated. The purpose of this observational study was to investigate the association between frailty, intraoperative cerebral oxygen saturation and post-operative complications in elderly patients undergoing non-cardiac surgery. METHODS: After approval from the Institutional Review Board, 25 elderly patients (>65 years) undergoing non-cardiac major surgery were included in this study. Pre-operatively, all included patients were assessed for frailty and classified into frail and non-frail groups. All patients had routine intraoperative monitors, and a cerebral oximeter applied during anaesthesia. The 'intraoperative' anaesthesiologist and the post-operative study investigator were blinded to cerebral oximeter readings throughout the study. The incidence of significant intraoperative cerebral oxygen desaturation, adverse post-operative outcomes and length of hospital stay were compared. Statistical significance was defined as a value of P < 0.05. RESULTS: We found that the frail group had more intraoperative cerebral desaturation (odds ratio [OR] [95% confidence interval [CI]]: 1.75 [1.11-2.75]) and longer median (interquartile range) length of hospital stay compared to the non-frail group (13.5 days [8.75-27.5] and 8 days [6-11], respectively). Furthermore, in patients with a low-baseline cerebral oxygen saturation (<55%), intraoperative cerebral desaturation (OR [95% CI]: 2.10 [1.00-4.42]), adverse post-operative outcomes (OR [95% CI]: 1.80 [1.00-3.23]) and median (interquartile range) length of hospital stay (15 days [9-31.5] vs. 9 days [6.25-13.75], P = 0.04) were significantly higher compared to subjects with higher baseline (≥55%) cerebral oxygen saturation. CONCLUSIONS: Frail patients have more intraoperative cerebral desaturation and longer lengths of hospital stay compared to non-frail patients.

Anesthetic considerations for endovascular abdominal aortic aneurysm repair.

Aneurysm is defined as a localized and permanent dilatation with an increase in normal diameter by more than 50%. It is more common in males and can affect up to 8% of elderly men. Smoking is the greatest risk factor for abdominal aortic aneurysm (AAA) and other risk factors include hypertension, hyperlipidemia, family history of aneurysms, inflammatory vasculitis, and trauma. Endovascular Aneurysm Repair [EVAR] is a common procedure performed for AAA, because of its minimal invasiveness as compared with open surgical repair. Patients undergoing EVAR have a greater incidence of major co-morbidities and should undergo comprehensive preoperative assessment and optimization within the multidisciplinary settings. In majority of cases, EVAR is extremely well-tolerated. The aim of this article is to outline the Anesthetic considerations related to EVAR.

Management of tracheomalacia in an infant with Tetralogy of Fallot.

Most infants with tracheomalacia do not need specific therapy as it usually resolves spontaneously by the age of 1-2 years. Severe forms of tracheomalacia characterized by recurrent respiratory infections require active treatment which includes chest physiotherapy, long term intubation or tracheostomy. Aortopexy seems to be the treatment of choice for secondary and even primary forms of severe tracheomalacia. Itentails tracking and suturing the anterior wall of the aorta to the posterior surface of the sternum. Consequently, the anterior wall of the trachea is also pulled forward preventing its collapse. A 3-month-old girl baby who was on ventilatory support for 2 months due to severe tracheomalacia associated with a cyanotic congenital heart disease underwent intracardiac repair and aortopexy along with Lecompte's procedure as all the conservative measures to wean off the ventilator failed. The baby was extubated on the third post-operative day and the post-operative period was uneventful.

Cardiac tamponade secondary to perforation of innominate vein following central line insertion in a neonate.

Cardiac tamponade following central line in a neonate is rare and an uncommon situation; however, it is potentially reversible when it is diagnosed in time. We report a case of cardiac tamponade following central line insertion. A 10-day-old 2.2 kg girl operated for obstructed total anomalous pulmonary venous connections had neckline slipped out during extubation. Attempted cannulations of right femoral vein were unsuccessful. At the end of the left internal jugular vein cannulaton, there was a sudden cardiorespiratory arrest. Immediate transthoracic echocardiogram showed left pleural and pericardial collection. Chest was opened and the catheter tip was seen in the thoracic cavity after puncturing the innominate vein. The catheter was removed and the vent was repaired.

Effect of levosimendan on hemodynamic changes in patients undergoing off-pump coronary artery bypass grafting: a randomized controlled study.

AIMS AND OBJECTIVE: We tested the hypothesis that use of levosimendan would be associated with better perioperative hemodynamics and cardiac function during off-pump coronary artery bypass grafting (OPCAB) in patients with good left ventricular function. MATERIALS AND METHODS: Thirty patients scheduled for OPCAB were randomized in a double-blind manner to receive either levosimendan 0.1 µg/kg/min or placebo after induction of general anesthesia. The hemodynamic variables were measured after induction of anesthesia, at 6 minute after application of tissue stabilizer for the anastomoses of left anterior descending artery, diagonal artery, left circumflex artery, and right coronary artery and at 6, 12, 18, and 24 hours after completion of surgery. RESULTS: Compared with placebo group, cardiac index (CI) was significantly higher and systemic vascular resistance index (SVRI) was significantly lower at 6, 12, 18, and 24 hour after surgery in levosimendan group. Norepinephrine was infused in 60% of the patients in the levosimendan group compared to 6.7% in the control group ( P < 0.05). Lactate and mixed venous oxygen saturation were not significantly different between groups. CONCLUSIONS: Levosimendan significantly increased CI and decreased SVRI after OPCAB but it did not show any outcome benefit in terms of duration of ventilation and intensive care unit stay.

A comparison of hemodynamic effects of levosimendan and dobutamine in patients undergoing mitral valve repair / replacement for severe mitral stenosis.

AIMS AND OBJECTIVES: We aimed to compare the hemodynamic effects of levosimendan and dobutamine in patients undergoing mitral valve surgery on cardiopulmonary bypass (CPB). MATERIALS AND METHODS: Sixty patients were divided into 2 groups of 30 each. Group-L patients received levosimendan 0.1 µg/kg/min and Group-D patients received dobutamine 5 µg/kg/min while weaning off CPB. Additional inotrope and/or vasoconstrictor were started based on hemodynamic parameters. Hemodynamic data were collected at the end and at 30 minutes after CPB, thereafter at 6, 12, 24, and 36 hours post-CPB. Mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI), and lactate levels were measured. RESULTS: Group-L showed increased requirement of inotropes and vasoconstrictors. The SVRI, CVP, and MAP were reduced more in Group-L. The CI was low in Group-L in the initial period when compared to Group-D. Later Group-L patients showed a statistically significant increase in CI even after 12 hrs of discontinuation of levosimendan infusion. The HR was increased more in Group-D. Lactate levels, intensive care unit stay, and duration of ventilation were similar in both groups. CONCLUSIONS: Levosimendan 0.1 µg/kg/min compared to dobutamine 5 µg/kg/min showed more vasodilation and lesser inotropic activity in patients undergoing mitral valve surgery for mitral stenosis. Levosimendan compared to dobutamine showed a statistically significant increase in CI even after 12 hrs of discontinuation. The requirement of another inotrope or vasopressor was frequent in levosimendan group.

The effects of preemptive pregabalin on attenuation of stress response to endotracheal intubation and opioid-sparing effect in patients undergoing off-pump coronary artery bypass grafting.

The clinical study was designed to evaluate and compare single preoperative dose of pregabalin to a placebo regarding hemodynamic responses to laryngoscopy and endotracheal intubation, to assess perioperative fentanyl requirement and any side-effects. It was a randomized, double-blind, placebo-controlled, parallel assignment, efficacy study. The study was done at a tertiary university hospital. This study was a comparison between two groups of 30 adult patients scheduled for elective off pump coronary artery bypass surgery. In the control group, the patients were given placebo capsules, and in the pregabalin group, the patients were given pregabalin 150 mg capsule orally 1 h before surgery. The patients were compared for hemodynamic changes before the start of the surgery, after induction, 1, 3, and 5 min after intubation. Additionally, fentanyl requirement during surgery and the first postoperative day was also compared. The present study shows that a single oral dose of 150 mg pregabalin given 1 h before surgery attenuated the pressor response to tracheal intubation in adults, but the drug did not show any effect on perioperative opioid consumption and was devoid of side-effects in the given dose.

The effects of dexmedetomidine on attenuation of stress response to endotracheal intubation in patients undergoing elective off-pump coronary artery bypass grafting.

This study was designed to study the efficacy of intravenous dexmedetomidine for attenuation of cardiovascular responses to laryngoscopy and endotracheal intubation in patients with coronary artery disease. Sixty adult patients scheduled for elective off-pump coronary artery bypass surgery were randomly allocated to receive dexmedetomidine (0.5 mcg/kg) or normal saline 15 min before intubation. Patients were compared for hemodynamic changes (heart rate, arterial blood pressure and pulmonary artery pressure) at baseline, 5 min after drug infusion, before intubation and 1, 3 and 5 min after intubation. The dexmedetomidine group had a better control of hemodynamics during laryngoscopy and endotracheal intubation. Dexmedetomidine at a dose of 0.5 mcg/kg as 10-min infusion was administered prior to induction of general anaesthesia attenuates the sympathetic response to laryngoscopy and intubation in patients undergoing myocardial revascularization. The authors suggest its administration even in patients receiving beta blockers.

Early extubation in tetralogy of Fallot patients after complete repair.

AIM: To document the feasibility of early extubation and to know the effect of age, weight, and post-operative right ventricle/left ventricle ratio in early extubation in intracardiac repair for tetralogy of Fallot. MATERIALS AND METHODS: This is a prospective study of 76 consecutive patients undergoing intracardiac repair between January, 2010 and April, 2010. The patients were compared between duration of ventilation with age, weight, and post-operative left ventricle/right ventricle ratio. RESULTS: In the age group less than 10 years, 47 patients were extubated within 4 hours and 12 after 4 hours. In the age group of 10-20 years, eight patients were extubated within 4 hours and seven patients after 4 hours. In the more than 20 years category, one patient was extubated within 4 hours and the other after 4 hours. In the weight category less than 10 kilograms, 17 patients were extubated within 4 hours and seven patients after 4 hours. In the 10-20 kilogram category, 27 patients were extubated before 4 hours and four patients after 4 hours. In the more than 20-kilogram category, 12 patients were extubated before 4 hours and nine patients after 4 hours. Where the ratio was less than 0.5, 47 patients were extubated within 4 hours and 14 patients after 4 hours. Where the ratio was greater than 0.5, nine patients were extubated within 4 hours and six patients after 4 hours. CONCLUSION: There was no correlation between duration of ventilation with age, weight, and right ventricle/left ventricle ratio. Early extubation in patients after intracardiac repair in tetralogy of Fallot is safe and effective.

Intraoperative anastomotic site detection and assessment of LIMA-to-LAD anastomosis by epicardial ultrasound in off-pump coronary artery bypass grafting--a prospective single-blinded study.

The study was done to detect the optimal site of left anterior descending (LAD) artery for grafting and for the assessment of geometrical and anatomical characteristics of left internal mammary artery (LIMA)-to-LAD artery anastomosis in elective off-pump coronary artery bypass grafting surgery. Fifteen consecutive patients who underwent coronary artery bypass graft (CABG) were included in the study. All the operations were performed by a single surgeon. Epicardial ultrasound probe was placed at the site of grafting for scanning and the site of anastomosis selected. The anticipated target site selected by the surgeon was scanned for patency, size, septal perforator branches, and presence of plaque and calcification. The surgeon identified the LAD artery in 12 patients. In three patients, the LAD artery was not visible. However, with epicardial ultrasound, the LAD artery was identified in all patients. In 6 of 15 patients, the anticipated target anastomotic site was changed to a clear segment either due to the presence of perforators or plaques or calcifications. In all 15 patients, the surgeon scored the anastomosis as good, based on his or her experience independent of the ultrasound image. The anastomotic score by the cardiac anesthesiologist showed 5 anastomoses with satisfactory results and 10 anastomoses with good results. The study demonstrates that epicardial ultrasound scanning with a 10-MHz transducer provides reliable information in choosing the proper anastomotic site and allows proper visualization of LIMA-to-LAD anastomosis. All these measurements are easily obtained without risk of any complications and the method is not time consuming.

Scimitar syndrome: experience with 6 patients.

Scimitar syndrome is a rare congenital anomaly characterized by anomalous pulmonary venous drainage to the inferior vena cava, causing a left-to-right shunt. Six patients with scimitar syndrome were diagnosed in our hospital between 2002 and 2008. There were 4 girls and 2 boys; 4 < 5 kg in weight, 2 < 8 kg in weight. Scimitar syndrome was suspected in 5 cases because of dextroversion, and diagnosed by color Doppler echocardiography in all 6 when a scimitar vein was detected entering the inferior vena cava. Computed tomography confirmed the diagnosis in all patients. Two patients had horseshoe lung, 2 had a unilobar right lung, 1 had a hypoplastic right lung, and 1 had a hypoplastic right lower lobe. Three patients had severe pulmonary arterial hypertension, 2 had moderate pulmonary arterial hypertension, and one had normal pulmonary arterial pressure. All patients had lower respiratory tract infections, volume loss of the right lung, a normal or hyperinflated left lung, dextroversion of the heart, and scimitar arteries from the descending aorta. Pneumonectomy was performed in 3 patients, lobectomy in 1, ligation of anomalous vessels in 1, and 1 died before surgery.