Physiological and Anesthetic Considerations of Safe and Optimal Pneumoperitoneal Pressures for Laparoscopic Surgeries in Children.

Context: In the era of minimally invasive surgeries, pediatric laparoscopic surgeries are now becoming the standard of care. Aim: In this study, we aim to determine the safe and optimal pneumoperitoneal pressures (PPs) for laparoscopic surgery in children aged 1-5 years, along with the technical ease for the surgeon. Settings and Design: Prospective, randomized, single-blinded study was conducted at SGPGI Lucknow. Materials and Methods: Children aged 1-5 years were randomized into Group I (n = 24): PP = 6-8 mmHg and Group II: (PP) = 9-10 mmHg. Hemodynamic, ventilatory, and blood gas changes were measured before CO2 insufflation (T0), 20 min after insufflation (T1), before desufflation (T2), and 10 min after desufflation (T3). Surgeon's technical ease of surgery, postoperative pain, the requirement of rescue analgesia, time to resume feeding, and complications were recorded and analyzed. Statistical Analysis Used: Paired t-test, Mann-Whitney test, and Wilcoxon signed-rank test were used for nonparametric/parametric data. Chi-square/Fisher's test was used for nominal data. Results: Partial pressure of CO2 (PaCO2) was significantly higher in Group II at T1, T2, and T3, requiring frequent changes in ventilatory settings. Postoperative pain scores were higher in Group II at 1, 6, and 12 h, requiring rescue analgesia. Surgeon's scores and hemodynamics were similar in both groups. Conclusions: Higher PP in Group II caused significant changes in PaCO2, end-tidal CO2, and postoperative pain requiring rescue analgesia, but blood gas changes were clinically insignificant and there were no significant changes in hemodynamic parameters. Since the surgeon's ease of performing surgery was similar in both groups, we recommend that laparoscopy in children aged 1-5 years can be started with lower PPs of 6-8 mmHg, which can be increased if needed based on the surgeon's comfort and the patient's body habitus.

Comparison of palonosetron and ondansetron in preventing postoperative nausea and vomiting in renal transplantation recipients: a randomized clinical trial

Abstract Background: End-stage renal diseases patients have a high risk of postoperative nausea and vomiting (PONV), which is multifactorial and need acute attention after renal transplantation for a successful outcome in term of an uneventful postoperative period. The study was done to compare the efficacy of palonosetron and ondansetron in preventing early and late-onset PONV in live donor renal transplantation recipients (LDRT). Methods: The prospective randomized double-blinded study was done on 112 consecutive patients planned for live donor renal transplantation. Patients of both sexes in the age group of 18-60 years were randomly divided into two groups: Group O (Ondansetron) and Group P (Palonosetron) with 56 patients in each group by computer-generated randomization. The study drug was administered intravenously (IV) slowly over 30 seconds, one hour before extubation. Postoperatively, the patients were accessed for PONV at 6, 24, and 72 hours using the Visual Analogue Scale (VAS) nausea score and PONV intensity scale. Results: The incidence of PONV in the study was found to be 30.35%. There was significant difference in incidence of PONV between Group P and Group O at 6 hours (12.5% vs. 32.1%, p = 0.013) and 72 hours (1.8% vs. 33.9%, p < 0.001), but insignificant difference at 24 hours (1.8% vs. 10.7%, p = 0.113). VAS-nausea score was significantly lower in Group P as compared to Group O at a time point of 24 hours (45.54 ± 12.64 vs. 51.96 ± 14.70, p = 0.015) and 72 hours (39.11 ± 10.32 vs. 45.7 ± 15.12, p = 0.015). Conclusion: Palonosetron is clinically superior to ondansetron in preventing early and delayed onset postoperative nausea and vomiting in live-related renal transplant recipients.

Comparison of Airway Ultrasound Indices and Clinical Assessment for the Prediction of Difficult Laryngoscopy in Elective Surgical Patients: A Prospective Observational Study.

BACKGROUND: Ultrasound is evolving as a probable tool in airway assessment. The upper airway is a superficial structure and has sonographically identifiable structures which makes it ideal for evaluation with the ultrasound. AIMS: The aim of this study was to evaluate the role of skin to hyoid and skin to thyrohyoid membrane distance in prediction of difficult laryngoscopy. SETTINGS AND DESIGN: This is a prospective observational study included 150 patients aged 18-60 years of American Society of Anesthesiologists Physical Status I and II scheduled to undergo surgery under general anesthesia requiring laryngoscopy and endotracheal intubation. MATERIALS AND METHODS: The modified Mallampati score, mouth opening, mentohyoid distance, thyromental distance were noted. Skin to hyoid bone distance and skin to thyrohyoid membrane distance were measured by ultrasound. Patients were clubbed retrospectively into easy and difficult laryngoscopy groups on the basis of Cormack Lehane grading, and the characteristics of both groups were compared. STATISTICAL ANALYSIS: Statistical Package for the Social Sciences, Version 23 was used for statistical analysis. Independent samples t-test was used to compare the means between difficult and easy laryngoscopy patients. Diagnostic accuracy of the significant (P < 0.05) variables between difficult and easy laryngoscopy patients was calculated using receiver operating characteristics curve in terms of their area under curve. Appropriate cutoff values (with corresponding sensitivity, specificity, and overall accuracy) were also identified. RESULTS: Out of 150 patients, 13 (8.7%) were identified as difficult laryngoscopy whereas 137 patients (91.3%) were identified as easy laryngoscopy. The demographics of both groups were comparable. Mentohyoid distance, skin to hyoid bone distance, and skin to thyrohyoid distance were statistically different between easy and difficult laryngoscopy patients, with lower mentohyoid distance and higher skin to hyoid bone distance and skin to thyrohyoid distance in difficult laryngoscopy patients. Diagnostic accuracy of the mentohyoid distance (70.3%) was slightly superior to skin to hyoid bone distance (67.1%) and skin to thyrohyoid distance (68.1%). CONCLUSION: Ultrasound measurements of skin to hyoid bone and skin to thyrohyoid membrane distance fail to eclipse clinical parameters in accurately predicting a difficult laryngoscopy.

A Simple Modification of Sphenopalatine Ganglion Block for Treatment of Postdural Puncture Headache: A Case Series.

To evaluate the efficacy of modified sphenopalatine ganglion block (MSPGB) to reduce the severity of post-dural puncture headache (PDPH). Five adult patients of both genders with age >18 years having PDPH intractable to conservative management were given modified sphenopalatine block in the postoperative period, and numeric rating scale (NRS) was recorded at regular intervals till the hospital discharge. MSPGB is a simple, noninvasive technique that provides instantaneous symptomatic relief in PDPH.

Comparison of palonosetron and ondansetron in preventing postoperative nausea and vomiting in renal transplantation recipients: a randomized clinical trial.

BACKGROUND: End-stage renal diseases patients have a high risk of postoperative nausea and vomiting (PONV), which is multifactorial and need acute attention after renal transplantation for a successful outcome in term of an uneventful postoperative period. The study was done to compare the efficacy of palonosetron and ondansetron in preventing early and late-onset PONV in live donor renal transplantation recipients (LDRT). METHODS: The prospective randomized double-blinded study was done on 112 consecutive patients planned for live donor renal transplantation. Patients of both sexes in the age group of 18-60 years were randomly divided into two groups: Group O (Ondansetron) and Group P (Palonosetron) with 56 patients in each group by computer-generated randomization. The study drug was administered intravenously (IV) slowly over 30 seconds, one hour before extubation. Postoperatively, the patients were accessed for PONV at 6, 24, and 72 hours using the Visual Analogue Scale (VAS) nausea score and PONV intensity scale. RESULTS: The incidence of PONV in the study was found to be 30.35%. There was significant difference in incidence of PONV between Group P and Group O at 6 hours (12.5% vs. 32.1%, p = 0.013) and 72 hours (1.8% vs. 33.9%, p < 0.001), but insignificant difference at 24 hours (1.8% vs. 10.7%, p = 0.113). VAS-nausea score was significantly lower in Group P as compared to Group O at a time point of 24 hours (45.54 ± 12.64 vs. 51.96 ± 14.70, p = 0.015) and 72 hours (39.11 ± 10.32 vs. 45.7 ± 15.12, p = 0.015). CONCLUSION: Palonosetron is clinically superior to ondansetron in preventing early and delayed onset postoperative nausea and vomiting in live-related renal transplant recipients.

To compare intraoperative goal directed fluid therapy by trans-oesophageal Doppler vis-à-vis FloTrac™ in patients undergoing living related renal transplantation-a prospective randomised controlled study.

BACKGROUND: Optimal intra-operative fluid therapy in renal transplantation (RT) is essential to ensure adequate graft function while preventing fluid overload related complications. This RCT was to compare the intraoperative goal directed fluid therapy (GDFT) based either on corrected flow time (CFT), measured by trans oesophageal Doppler (TED) or on the stroke volume variation (SVV), by FloTrac in patients undergoing living donor RT. METHODS: This prospective, randomised controlled trial (RCT) was done on 60 end stage renal disease (ESRD) patients, American Society of Anaesthesiologists(ASA) grade III-IV, age 18 to 65 years of either sex, scheduled for living donor RT under general anaesthesia. They were randomly divided into two groups: TED group (n = 30) and FloTrac™ group (n = 30) and administered GDFT, based upon CFT (TED) and SVV (FloTrac™). The primary outcome was to compare the total fluid and number of fluid boluses administered intraoperatively, while the secondary outcomes were to compare any postoperative complications due to fluid overload and allograft function, assessed by serial serum creatinine levels up to 90 days postoperatively. RESULTS: The mean total intra-operative fluid [3991.67 ± 856.32 vs. 3543.33 ± 1131.35, P = 0.089] and the amount of fluid administered per kg body weight per hour [13.32 ± 4.67 vs. 11.82 ± 4.76, P = 0.222] were lesser in the FloTrac compared to TED group, though not statistically significant. However, the postoperative incidence of allograft dysfunction, including rejection (P = 0.743) and acute tubular necrosis (ATN) (P = 0.999), and other complications (P = 0.643) were comparable. CONCLUSIONS: Both TED and FloTrac devices can be used effectively to guide GDFT in RT, However, lesser total fluid was required in the FloTrac group, which may lead to a lesser number of fluid-related postoperative complications.

Ultrasound-Guided Suprainguinal Fascia Iliaca Compartment Block for Postoperative Analgesia in Patients Undergoing Hip and Femur Surgeries: A Retrospective Analysis.

CONTEXT: Fractures of femur and hip surgeries pose a challenge because of excruciating pain. Fascia iliaca compartment block is an effective and easily learned procedure to decrease postoperative pain score and dosage of opioid. Many adjuvants are combined with local anesthetics to prolong the postoperative analgesia. AIMS: The aim was to study duration of postoperative analgesia in terms of Numeric Rating Scale (NRS), number of times rescue analgesic used, any adverse effect, and patient satisfaction score. SETTINGS AND DESIGN: Operation theatre of Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow. MATERIALS AND METHODS: The present study was retrospective study with 203 patients evaluated. Based on the combination of the anesthesia and drugs, study patients were divided into six groups. Pain scores were assessed at 6 hourly intervals for 24 h. STATISTICAL ANALYSIS USED: Kruskal-Wallis H-test used to compare NRS as well as age and duration of anesthesia. Chi-square test/Fisher's exact test used to compare the proportions. RESULTS: Postoperative analgesia was comparable and insignificant (P > 0.05) at 0, 6, 12 h in all six groups. Better postoperative analgesia was observed with dexmedetomidine and dexamethasone as adjuvant at 18 h, dexmedetomidine as adjuvant in comparison to dexamethasone as adjuvant at 24 h. Rescue analgesia in postoperative period was required maximum in plain bupivacaine. Satisfaction levels were good and excellent in dexmedetomidine and dexamethasone as adjuvant. CONCLUSIONS: Addition of dexmedetomidine to bupivacaine provides longer duration, good quality postoperative analgesia, reduced requirement for rescue analgesic, lesser postoperative nausea and vomiting, and better satisfaction levels.

Anesthetic techniques: focus on transversus abdominis plane (TAP) blocks.

Transverse abdominis plane (TAP) blocks, over the past decade, have emerged as a reliable tool in multimodal analgesia. Although they block only the somatic component of pain, studies have still revealed a consistent benefit in the first 24-48 hours after surgery in terms of pain scores and overall opioid consumption. The safety and dependability has increased with ultrasound usage. The aim of this review is to help the reader appreciate the applied anatomy required for a TAP block and its congeners, to standardize its nomenclature, and to help choose between variants of a TAP block and its complications and safety profile.

Dexmedetomidine for prevention of early postoperative catheter-related bladder discomfort in voluntary kidney donors: Prospective, randomized, double-blind, placebo-controlled trial.

BACKGROUND AND AIMS: Catheter-related bladder discomfort (CRBD) has started to gain recognition as a problem in early postoperative care. Dexmedetomidine reduces bladder contractility via M3 muscarinic receptor antagonism and α-2 receptor agonism, apart from its concomitant therapeutic benefits, such as sedation and sympatholysis, in a postoperative period. We, therefore, evaluated the efficacy of dexmedetomidine in reducing incidence and severity of CRBD. MATERIAL AND METHODS: This prospective, randomized, double-blind, placebo-controlled trial done on 110 voluntary kidney donors for live related kidney transplantations were planned for laparoscopic donor nephrectomy. The donors were of ages 18-60 years, American Society of Anesthesiologists physical status I and II of either sex. The control group received 20 ml normal saline (NS) intravenous (IV) infusion over 15 min, whereas the dexmedetomidine group received dexmedetomidine 1 µg/kg made in 20 ml NS as IV infusion over 15 min. The incidence and severity of CRBD were recorded as primary endpoints up to 12 h in early postoperative period. The incidence of bladder discomfort was analysed by Fisher's exact test and severity of bladder discomfort by Mann Whitney U test. RESULTS: The incidence of CRBD on arrival at postoperative care unit was 18% in dexmedetomidine group compared to 42% in control group (P < 0.05). The incidence and severity of CRBD reduced in dexmedetomidine group at 0, 2, and 4 h compared with control group (P < 0.05). CONCLUSIONS: Dexmedetomidine 1 µg/kg administered IV to patients 30 min before extubation reduces the incidence and severity of CRBD in early postoperative settings with no adverse effects.

Efficacy of trans abdominis plane block for post cesarean delivery analgesia: A double-blind, randomized trial.

BACKGROUND: The transverse abdominis plane (TAP) block, a regional block provides effective analgesia after lower abdominal surgeries if used as part of multimodal analgesia. In this prospective, randomized double-blind study, we determined the efficacy of TAP block in patients undergoing cesarean section. MATERIALS AND METHODS: Totally, 62 parturients undergoing cesarean section were randomized in a double-blind manner to receive either bilateral TAP block at the end of surgery with 20 ml of 0.25% bupivacaine or no TAP block, in addition to standard analgesic comprising 75 mg diclofenac 8 hourly and intravenous patient-controlled analgesia (PCA) tramadol. Each patient was assessed at 0, 4, 8, 12, 24, 36, and 48 h after surgery by an independent observer for pain at rest and on movement using numeric rating scale of 0-10, time of 1(st) demand for tramadol, total consumption of PCA tramadol, satisfaction with pain management and side effects. RESULTS: Use of tramadol was reduced in patients given TAP block by 50% compared to patients given no block during 48 h after surgery (P < 0.001). Pain scores were lower both on rest and activity at each time point for 24 h in study group (P < 0.001), time of first analgesia was significantly longer, satisfaction was higher, and side effects were less in study group compared to control group. CONCLUSION: Transverse abdominis plane block was effective in providing analgesia with a substantial reduction in tramadol use during 48 h after cesarean section when used as adjunctive to standard analgesia.

Extra corporeal carbon dioxide removal: A reliable modality in refractory hypercapnia to prevent invasive ventilation.

Extracorporeal carbon dioxide removal (ECCO2R) is a valid alternative to consider in hypercapnic respiratory failure in chronic obstructive pulmonary disease (COPD) patients to avoid invasive ventilation when noninvasive ventilation fails. Here we report a similar case, after obtaining informed consent, where a patient suffering from severe hypercapnic respiratory failure due to COPD, was selected for ECCO2R and improved remarkably.

Accidental placement of central venous catheter in lung parenchyma causing hydrothorax.

Central venous catheterization is associated with its share of complications. Most of these complications can be avoided and treated by appropriate patient selection, careful insertion technique and vigilance following catheter insertion. We report a patient presenting with unilateral hydrothorax due malposition of central venous catheter in lung parenchyma. Prompt recognition of complication and its treatment remedied the situation.

Comparison of clonidine and dexmedetomidine for short-term sedation of intensive care unit patients.

BACKGROUND AND OBJECTIVES: Patients on mechanical ventilation in intensive care unit (ICU) are often uncomfortable because of anxiety, pain, and endotracheal intubation; therefore, require sedation. Alpha-2 agonists are known to produce sedation. We compared clonidine and dexmedetomidine as sole agents for sedation. STUDY DESIGN: Prospective, randomized, controlled open-label study. MATERIALS AND METHODS: A total of 70 patients requiring a minimum of 12 h of mechanical ventilation with concomitant sedation, were randomly allocated into two groups. Group C (n = 35) received intravenous (IV) clonidine (1 µg/kg/h titrated up to 2 µg/kg/h to attain target sedation), and Group D (n = 35) received IV dexmedetomidine for sedation (loading 0.7 µg/kg and maintenance 0.2 µg/kg/h titrated up to 0.7 µg/kg/h to achieve target sedation). A Ramsay Sedation Score of 3-4 was considered as target sedation. Additional sedation with diazepam was given when required to achieve target sedation. The quality of sedation, hemodynamic changes and adverse effects were noted and compared between the two groups. RESULTS: Target sedation was achieved in 86% observations in Group D and 62% in Group C (P = 0.04). Additional sedation was needed by more patients in Group C compared with Group D (14 and 8 in Groups C and D, respectively, P = 0.034), mainly due to concomitant hypotension on increasing the dose of clonidine. Hypotension was the most common side-effect in Group C, occurring in 11/35 patients of Group C and 3/35 patients of Group D (P = 0.02). Rebound hypertension was seen in four patients receiving clonidine, but none in receiving dexmedetomidine. CONCLUSION: Both clonidine and dexmedetomidine produced effective sedation; however, the hemodynamic stability provided by dexmedetomidine gives it an edge over clonidine for short-term sedation of ICU patients.