Arousal time from sedation during spinal anaesthesia for elective infraumbilical surgeries: Comparison between propofol and midazolam.

BACKGROUND AND AIMS: Studies have already compared propofol and midazolam as sedatives during regional anaesthesia. A few studies have focused on recovery characteristics and very few have utilised both instrumental and clinical sedation monitoring for assessing recovery time. This study was designed primarily to compare arousal time from sedation using propofol with that of midazolam during spinal anaesthesia for infraumbilical surgeries, while depth of sedation was monitored continuously with bispectral index (BIS) monitor. The correlation between the BIS score and observer's assessment of awareness/sedation (OAA/S) score during recovery from sedation was also studied. METHODS: A total of 110 patients were randomly assigned to receive either propofol (Group P, n = 55) or midazolam (Group M, n = 55). Patients in the Group P received bolus of propofol (1 mg/kg), followed by infusion at 3 mg/kg/h; Group M received bolus of midazolam (0.05 mg/kg), followed by infusion at 0.06 mg/kg/h and titration until BIS score 70 was achieved and maintained between 65 and 70. OAA/S score was noted at BIS 70 and again at BIS 90 during recovery. The time to achieve OAA/S score 5 was noted. Spearman's correlation was calculated between the arousal time from sedation and the time taken to reach an OAA/S score of 5 in both the study groups. RESULTS: Arousal time from sedation was found lower for Group P compared to Group M (7.54 ± 3.70 vs. 15.54 ± 6.93 min, respectively, P = 0.000). The time taken to reach OAA/S score 5 was also found to be lower for Group P than Group M (6.81 ± 2.54 min vs. 13.51 ± 6.24 min, respectively, P = 0.000). CONCLUSION: A shorter arousal time from sedation during spinal anaesthesia can be achieved using propofol compared with midazolam, while depth of sedation was monitored with BIS monitor and OAA/S score. Both objective and clinical scoring correlate strongly during recovery from sedation.

Comparison of four techniques of nasogastric tube insertion in anaesthetised, intubated patients: A randomized controlled trial.

BACKGROUND AND AIMS: Insertion of nasogastric tubes (NGTs) in anaesthetised, intubated patients with a conventional method is sometimes difficult. Different techniques of NGT insertion have been tried with varying degree of success. The aim of this prospective, randomised, open-label study was to evaluate three modified techniques of NGT insertion comparing with the conventional method in respect of success rate, time taken for insertion and the adverse events. METHODS: In the operation theatre of general surgery, the patients were randomly allocated into four groups: Group C (control group, n = 54), Group W (ureteral guide wire group, n = 54), Group F (neck flexion with lateral pressure, n = 54) and Group R (reverse Sellick's manoeuvre, n = 54). The number of attempts for successful NGT insertion, time taken for insertion and adverse events were noted. RESULTS: All the three modified techniques were found more successful than the conventional method on the first attempt. The least time taken for insertion was noted in the reverse Sellick's method. However, on intergroup analysis, neck flexion and reverse Sellick's methods were comparable but significantly faster than the other two methods with respect to time taken for insertion. CONCLUSION: Reverse Sellick's manoeuver, neck flexion with lateral neck pressure and guide wire-assisted techniques are all better alternatives to the conventional method for successful, quick and reliable NGT insertion with permissible adverse events in anaesthetised, intubated adult patients. Further studies after eliminating major limitations of the present study are warranted to establish the superiority of any one of these modified techniques.

Bispectral index score and observer's assessment of awareness/sedation score may manifest divergence during onset of sedation: Study with midazolam and propofol.

BACKGROUND: Correlation between the clinical and electroencephalogram-based monitoring has been documented sporadically during the onset of sedation. Propofol and midazolam have been studied individually using the observer's assessment of awareness/sedation (OAA/S) score and Bispectral index score (BIS). The present study was designed to compare the time to onset of sedation for propofol and midazolam using both BIS and OAA/S scores, and to find out any correlation. METHODS: A total of 46 patients (18-60 years, either sex, American Society of Anesthesiologists (ASA) I/II) posted for infraumbilical surgeries under spinal anaesthesia were randomly allocated to receive either injection propofol 1 mg/kg bolus followed by infusion 3 mg/kg/h (Group P, n=23) or injection midazolam 0.05 mg/kg bolus followed by infusion 0.06 mg/kg/h (Group M, n=23). Spinal anaesthesia was given with 2.5 ml to 3.0 ml of 0.5% bupivacaine heavy. When sensory block reached T6 level, sedation was initiated. The time to reach BIS score 70 and time to achieve OAA/S score 3 from the start of study drug were noted. OAA/S score at BIS score 70 was noted. Data from 43 patients were analyzed using SPSS 12 for Windows. RESULTS: Time to reach BIS score 70 using propofol was significantly lower than using the midazolam (P<0.05). Time to achieve OAA/S score 3 using propofol was comparable with midazolam (P=0.358). CONCLUSION: A divergence exists between the time to reach BIS score 70 and time to achieve OAA/S score 3 using midazolam, compared with propofol, during the onset of sedation.

Efficacy of intravenous dexamethasone to reduce incidence of postoperative sore throat: A prospective randomized controlled trial.

BACKGROUND: Sore throat and hoarseness are common complications of endotracheal intubation. It may be very distressing for the patient and may lead to sleep disturbances and unpleasant memories. MATERIALS AND METHODS: This prospective double-blinded randomized control trial was aimed to determine the efficacy of prophylactic intravenous dexamethasone to reduce the incidence of postoperative sore throat at 1 hour after tracheal extubation. Ninety six patients of either sex aged between 18 to 60 years scheduled for elective surgeries needing general anesthesia with endotracheal intubation, were randomly allocated into two groups A and B. The patients received either intravenous 0.2 mg/kg dexamethasone (group A, n = 48) or normal saline (group B, n = 47) just before induction. Trachea was intubated with appropriate size disposable endotracheal tubes for securing the airway. Follow up for the incidence of sore throat, cough and hoarseness was done at 1, 6 and 24 hours post-extubation. RESULTS: At 1 hour post-extubation, the incidence of sore throat in the control group was 48.9% compared with 18.8% in the dexamethasone group (P<0.002). CONCLUSIONS: Prophylactic intravenous dexamethasone in a dose of 0.2 mg/kg can reduce the incidence of postoperative sore throat at 1 hour post-extubation by around 30%, with the efficacy being around 60%.

Intravenous infusion of ketamine-propofol can be an alternative to intravenous infusion of fentanyl-propofol for deep sedation and analgesia in paediatric patients undergoing emergency short surgical procedures.

BACKGROUND: Paediatric patients often present with different painful conditions that require immediate surgical interventions. Despite a plethora of articles on the ketamine-propofol combination, comprehensive evidence regarding the suitable sedoanalgesia regime is lacking due to heterogeneity in study designs. METHODS: This prospective, randomized, double-blind, active-controlled trial was conducted in 100 children, of age 3-14 years, American Society of Anesthesiologist physical status IE-IIE, posted for emergency short surgical procedures. Patients were randomly allocated to receive either 2 mL of normal saline (pre-induction) plus calculated volume of drug from the 11 mL of ketamine-propofol solution for induction (group PK, n=50) or fentanyl 1.5 µg/kg diluted to 2 mL with normal saline (pre-induction) plus calculated volume of drug from the 11 mL of propofol solution for induction (group PF, n=50). In both the groups, the initial bolus propofol 1 mg/kg i.v. (assuming the syringes contained only propofol, for simplicity) was followed by adjusted infusion to achieve a Ramsay Sedation Scale score of six. Mean arterial pressure (MAP) was the primary outcome measurement. RESULTS: Data from 48 patients in group PK and 44 patients in group PF were available for analysis. Hypotension was found in seven patients (14.6%) in group PK compared with 17 (38.6%) patients in group PF (P=0.009). Intraoperative MAP was significantly lower in group PF than group PK when compared with baseline. CONCLUSION: The combination of low-dose ketamine and propofol is more effective and a safer sedoanalgesia regimen than the propofol-fentanyl combination in paediatric emergency short surgical procedures in terms of haemodynamic stability and lesser incidence of apnoea.

Multiple-injection thoracic paravertebral block as an alternative to general anaesthesia for elective breast surgeries: A randomised controlled trial.

BACKGROUND: General anaesthesia is currently the conventional technique used for surgical treatment of breast lump. Paravertebral block (PVB) has been used for unilateral procedures such as thoracotomy, breast surgery, chest wall trauma, hernia repair or renal surgery. METHODS: We compared unilateral thoracic PVB with general anaesthesia (GA) in 60 consenting ASA physical status I and II female patients of 18-65 years age, scheduled for unilateral breast surgery. Patients were randomly assigned into two groups, P (n=30) or G (n=30), to receive either PVB or GA, respectively. RESULTS: The average time to first post-operative analgesic requirement at visual analogue scale score≥4 (primary endpoint) was significantly longer in group P (303.97±76.08 min) than in group G (131.33±21.36 min), P<0.001. Total rescue analgesic (Inj. Tramadol) requirements in the first 24 h were 105.17±20.46 mg in group P as compared with 176.67±52.08 mg in group G (P<0.001). Significant post-operative nausea and vomiting requiring treatment occurred in three (10.34%) patients of the PVB group and eight (26.67%) patients in the GA group. CONCLUSION: The present study concludes that unilateral PVB is more efficacious in terms of prolonging post-operative analgesia and reducing morbidities in patients undergoing elective unilateral breast surgery.

Evaluation of autologous bone marrow in wound healing in animal model: a possible application of autologous stem cells.

A study was conducted to evaluate the potential of autologous bone marrow-derived cells in comparison with buffy coat of autologous blood for rapid cutaneous wound healing in rabbit model. Three square full-thickness skin excisional wounds were created in 15 selected experimental animals (rabbit) divided randomly into three groups. The wound was treated with autologous bone marrow cells in plasma (group 1), buffy coat of blood in plasma (group 2) and autologous plasma as control (group 3). Wounds were observed for 30 days for granulation tissue formation, biochemical, histomorphological and histochemical evaluation. In this study, granulation tissue appeared significantly lesser in wounds of group 3 animals followed by group 2 and 1 animals. Neovascularisation, granulation tissue formation, denser, thicker and better arranged collagen fibres, reticulin fibres and elastin fibres formation was more in group 1 as compared with other groups. It was concluded that the application of bone marrow-derived nucleated cells into the wound margins resulted in early and significantly faster rate of complete healing as compared with buffy coat of autologous blood and autologous plasma (control). This approach may be beneficial in various surface wounds that heal at a slower rate and recommended for healing of various complicated wound in future.

Fatal thyrocardiac event.

Atrial fibrillation occurs frequently (2-20%) in chronic hyperthyroidism patients. Poorly treated thyrotoxic patients may present with a life-threatening cerebrovascular accident giving little scope to revert the situation. At times, it is difficult to make a patient euthyroid with conventional management. The definitive treatment of choice is (131)I, radioiodine. An adjusted dose of an oral anticoagulant is highly efficacious for the prevention of all types of strokes. Timely intervention by a skilled airway manager with right instruments is the key to success in airway management. A 50-year-old thyrotoxic, semiconscious male presented with a sudden onset of haemiplegia. He had chronic AF, a huge thyroid swelling with gross tracheal deviation and dilated cardiomyopathy. A CT scan showed infarction in the left middle cerebral artery territory. After initial improvement with conservative management, patient's condition deteriorated in the next 48 h. Repeat CT scan showed increase in the infarct size with haemorrhage and midline shift. Finally, he died despite all resuscitative measures.

Effect of clonidine as adjuvant in bupivacaine-induced supraclavicular brachial plexus block: A randomized controlled trial.

OBJECTIVE: Clonidine has been used as adjuvant to local anesthetics in order to extend the duration of analgesia in various regional and central neuraxial blocks. It is previously reported that clonidine added to bupivacaine increases analgesia duration in brachial plexus block. We evaluated the effect of this combination in supraclavicular brachial plexus block for upper limb orthopedic procedures. MATERIALS AND METHODS: A randomized double-blind placebo controlled trial was done with 70 patients of American Society of Anesthesiologists Grade I or II status undergoing upper limb orthopedic procedures. Group A (n = 35) patients received 25 ml of 0.5% bupivacaine and 0.2 ml (30 mcg) clonidine, whereas group B (n = 35) received 25 ml of 0.5% bupivacaine and 0.2 ml normal saline through a supraclavicular approach for brachial plexus block. Vital parameters were recorded 10 min prior to block placement and every 3 min thereafter till the end of the procedure. Onset and duration of both sensory and motor blocks and sedation score were recorded. All patients were observed in postanesthesia care unit and received tramadol injection as soon as they complained of pain as rescue analgesic. Duration of analgesia was taken as the time from placement of block till injection of rescue analgesic. RESULTS: Analgesia duration was 415.4 +/- 38.18 min (mean +/- standard deviation) in Group A (clonidine) compared to 194.2 +/- 28.74 min in Group B (control). No clinically significant difference was observed in heart rate, blood pressure, and oxygen saturation. Sedation score was higher in the clonidine group. CONCLUSION: Addition of a small dose of clonidine to 0.5% bupivacaine significantly prolonged the duration of analgesia without producing any clinically important adverse reactions other than sedation.