Importance of Routine Laboratory Investigations Before Elective Surgery.

BACKGROUND AND AIMS:  Certain routine pre-operative laboratory investigations are performed in all patients before elective surgeries. We conducted this study to assess the value of routine pre-operative tests in the ASA (American Society of Anesthesiologists) Grade I and II adults undergoing elective surgery and their influence in the conduct of anaesthesia together with the costs incurred on unwarranted tests. METHODS: A total of 1271 patients posted for elective surgery under anaesthesia were recruited. Each patient attended the Pre-Anaesthetic Checkup Clinic and underwent clinical evaluation and investigations according to institutional policy. Demographic data and other characteristics were recorded, along with the results of laboratory test, any peri-operative intervention done as a result of abnormality and the cost incurred on tests. RESULTS: Majority of the patients belonged to ASA status I (74%) and underwent moderately invasive surgery (78%). The total number of routine investigations performed was 8015. Of these, 351 (4.37%) tests had abnormal results. Amongst these 333 (4.15%) abnormalities were suspected clinically and peri-operative intervention was only performed in 0.43% of patients. Anemia was the most common abnormal finding. Abnormal blood glucose was detected in 6 patients who were not clinically suspected. Abnormal electrocardiograph (ECG) was found in 54 patients. However, the intervention was required only in 13 patients. No intervention was required because of abnormal findings of the chest X-Ray. In total cost of investigations, only 6.9% was contributed by abnormal investigations and the rest was spent on the normal tests. CONCLUSION: The incidence of tests with abnormal results was very low in our study, and less than 1% of the patients with abnormal tests required changes in their peri-anaesthetic management. No major complications were seen in any patient with normal or abnormal test results. Most of the expenses (93%) were related to the normal test, which did not contribute to the perioperative management, safety and outcome of the patient. Thus, pre-operative investigations should be judiciously advised to avoid inconvenience, surgical delays and escalation of the costs of surgical care.

Evaluation of I-Gel™ versus Classic LMA™ for Airway Management by Paramedics and Medical Students: A Manikin Study.

BACKGROUND AND AIM: Airway management is a lifesaving skill which all health-care workers should possess. Currently, most of the resuscitation councils recommend supraglottic airway devices as the technique of choice for airway management during cardiopulmonary resuscitation by health-care providers without expertise in tracheal intubation. This is because of its high first-pass success rate and easy to acquire and retain skill even by novices. MATERIALS AND METHODS: The present study was planned to compare the efficacy of two commonly available supraglottic airway devices, classic LMA (cLMA) and I-gel in securing airway in adult manikin by inexperienced persons (58 paramedics and 46 medical students), after a brief training. Our primary aim was to determine the first attempt success rate, and other parameters studied were the time and ease of insertion, overall success rate, and preference for device. RESULTS: The first-attempt success rate of I-gel was higher in both groups of participants (74% in students and 69% in paramedicals) compared to that of cLMA (70% in l students and 53% in paramedics) although the overall success was the same. Majority of participants could secure airway quickly and easily by I-gel than by cLMA. More than 90% of participants preferred I-gel over cLMA. CONCLUSION: This study shows that inexperienced persons could learn to place the I-Gel and cLMA successfully in the manikin after a brief training in manikin. The first-attempt success rate and insertion of I-gel was easier and faster than that of cLMA by both groups of participants and most participants preferred I-gel due to ease of handling.

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.

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.

Anaesthesia gas supply: gas cylinders.

Invention of oxygen cylinder was one of the most important developments in the field of medical practice. Oxygen and other gases were compressed and stored at high pressure in seamless containers constructed from hand-forged steel in1880. Materials technology has continued to evolve and now medical gas cylinders are generally made of steel alloys or aluminum. The filling pressure as well as capacity has increased considerably while at the same time the weight of cylinders has reduced. Today oxygen cylinder of equivalent size holds a third more oxygen but weighs about 20 kg less. The cylinders are of varying sizes and are color coded. They are tested at regular intervals by the manufacturer using hydraulic, impact, and tensile tests. The top end of the cylinder is fitted with a valve with a variety of number and markings stamped on it. Common valve types include: Pin index valve, bull nose, hand wheel and integral valve. The type of valve varies with cylinder size. Small cylinders have a pin index valve while large have a bull nose type. Safety features in the cylinder are: Color coding, pin index, pressure relief device, Bodok seal, and label attached etc., Safety rules and guidelines must be followed during storage, installation and use of cylinders to ensure safety of patients, hospital personnel and the environment.

Safety and efficacy of low-molecular-weight heparins in prophylaxis of deep vein thrombosis in postoperative/ICU patients: A comparative study.

BACKGROUND: Venous thromboembolism (VTE), although a very common problem in everyday clinical practice, remains asymptomatic in most cases. Clinical diagnosis helps identify those who are going to have thromboembolic episode. A combination of clinical scoring systems like Wells' score and D-dimer assay provide a useful diagnostic tool. Trauma (surgical or accidental) and critically ill patients are found to have greatest risk. Enoxaparin and dalteparin are amongst the most common low-molecular-weight heparins (LMWHs) used for deep venous thrombosis (DVT) prophylaxis in such patients. AIM: The present study is designed to compare their role in preventing DVT in postoperative or critically ill patients and to determine their relative safety profiles. MATERIALS AND METHODS: The study included 36 critically ill adult patients. All the patients were allocated into three groups of 12 patients each. Group I patients received no prophylaxis, group II received inj. enoxaparin s/c 0.6-0.8 mg/kg twice daily, and group III received inj. dalteparin s/c 125-250 units/kg once daily. Routine investigations and coagulation profile were recorded on admission to intensive care unit (ICU) and at every third day thereafter. Patients were daily assessed for pretest probability of DVT using Wells' scoring, and D-dimer test was done on the 7(th) day. Occurrence of any bleeding (visible or occult) was noted, and incidence of DVT was determined in each group using positive results of D-dimer test and the clinical assessment with Wells' score. RESULTS: A significant difference in Wells' score (P < 0.05) was found between groups I and III on day 5 and day 7. A lower, but insignificant difference in the incidence of DVT was found between the study and control groups. No significant difference in major bleeding or other side effects was found. Better hemodynamic status and arterial blood gases in the study groups may indirectly refer to absence of asymptomatic DVT or silent pulmonary embolism in this group. CONCLUSION: The present study suggests that LMWHs, namely, enoxaparin and dalteparin, provide effective means of preventing DVT in high-risk, critically ill or postoperative patients, without causing any significant increase in the risk of bleeding or other side effects. Dalteparin appears to be unaffected by low creatinine clearance as explained by its clearance by a non-saturable mechanism. Still, a more extensive study with larger population is needed to make the outcomes worthwhile.

Role of routine laboratory investigations in preoperative evaluation.

Traditionally, routine investigations prior to surgery are considered an important element of preanesthetic evaluation to determine the fitness for anesthesia and surgery. During past few decades this practice has been a subject of close scrutiny due to low yield and high aggregate cost. Performing routine screening tests in patients who are otherwise healthy is invariably of little value in detecting diseases and in changing the anesthetic management or outcome. Thorough history and investigation of positive answers by the clinicians, combined with physical examination of patient represents the best method for screening diseases followed by few selective tests as guided by patient's health condition, invasiveness of planned surgery and potential for blood loss. A large number of investigations which are costly to pursue often detect minor abnormalities of no clinical relevance, may be risky to patients, cause unnecessary delay or cancellation of surgery, and increase medico-legal liability. An approach of selective testing reduces cost without sacrificing safety or quality of surgical care.

The comparison of Proseal laryngeal mask airway and endotracheal tube in patients undergoing laparoscopic surgeries under general anaesthesia.

Aims to compare the efficacy of Proseal laryngeal mask airway(PLMA) and endotracheal tube (ETT) in patients undergoing laparoscopic surgeries under general anaesthesia. This prospective randomised study was conducted on 60 adult patients, 30 each in two groups, of ASA I-II who were posted for laparoscopic procedures under general anaesthesia. After preoxygenation, anaesthesia was induced with propofol, fentanyl and vecuronium. PLMA or ETT was inserted and cuff inflated. Nasogastric tube (NGT) was passed in all patients. Anaesthesia was maintained with N(2) O, O(2), halothane and vecuronium. Ventilation was set at 8 ml/kg and respiratory rate of 12/min. The attempts and time taken for insertion of devices, haemodynamic changes, oxygenation, ventilation and intraoperative and postoperative laryngopharyngeal morbidity (LPM) were noted. There was no failed insertion of devices. Time taken for successful passage of NGT was 9.77 s (6-16 s) and 11.5 s (8-17 s) for groups P and E, respectively. There were no statistically significant differences in oxygen saturation (SpO(2)) or end-tidal carbon dioxide (EtCO(2)) between the two groups before or during peritoneal insufflation. Median (range) airway pressure at which oropharyngeal leak occurred during the leak test with PLMA was 35 (24-40) cm of H(2)O. There was no case of inadequate ventilation, regurgitation, or aspiration recorded. No significant difference in laryngopharyngeal morbidity was noted. A properly positionedPLMA proved to be a suitable and safe alternative to ETT for airway management in elective fasted, adult patients undergoing laparoscopic surgeries. It provided equally effective pulmonary ventilation despite high airway pressures without gastric distention, regurgitation, and aspiration.

Low Dose Epidural Analgesia During Labor: Comparison Between Patient Controlled Epidural Analgesia with Basal Continuous Infusion and Intermittent Bolus Technique.

OBJECTIVES: To compare the efficacy and safety of patient controlled epidural analgesia with basal continuous infusion versus intermittent bolus for labor analgesia using fentanyl and bupivacaine. METHODS: In this prospective study, 60 parturients having singleton term uncomplicated pregnancy in early active labor were included. 30 parturients were allocated to receive patient controlled epidural analgesia + basal continuous infusion (Group-A) and 30 received intermittent bolus on demand (Group-B). Efficacy of technique was assessed in terms of quality of analgesia on 0-10 cm verbal analogue scale. Effect on labor was assessed by duration of labor, mode of delivery, and parturient's satisfaction. Neonatal outcome was measured by Apgar score. Data were expressed as mean ± SD and analysed using Student 't' test and chi square test where appropriate. P < 0.05 was considered statistically significant. RESULTS: Analgesic efficacy of both the groups was comparable. Maternal satisfaction was better in group A than in group B but the results did not achieve statistical significance. Effect on labor and neonatal outcome were comparable. CONCLUSIONS: Both the techniques appear to be safe for the mother and neonate with excellent analgesic efficacy. In a busy obstetric unit with increased demand of epidural analgesia, patient controlled epidural analgesia with basal continuous infusion may be preferred.

Comparison of two approaches of infraclavicular brachial plexus block for orthopaedic surgery below mid-humerus.

The brachial plexus in infraclavicular region can be blocked by various approaches. Aim of this study was to compare two approaches (coracoid and clavicular) regarding success rate, discomfort during performance of block, tourniquet tolerance and complications. The study was randomised, prospective and observer blinded. Sixty adult patients of both sexes of ASA status 1 and 2 requiring orthopaedic surgery below mid-humerus were randomly assigned to receive nerve stimulator guided infraclavicular brachial plexus block either by lateral coracoid approach (group L, n = 30) or medial clavicular approach (group M, n = 30) with 25-30 ml of 0.5% bupivacaine. Sensory block in the distribution of five main nerves distal to elbow, motor block (Grade 1-4), discomfort during performance of block and tourniquet pain were recorded by a blinded observer. Clinical success of block was defined as the block sufficient to perform the surgery without any supplementation. All the five nerves distal to elbow were blocked in 77 and 67% patients in groups L and M respectively. Successful block was observed in 87 and 73% patients in groups L and M, respectively (P > 0.05). More patients had moderate to severe discomfort during performance of block due to positioning of limb in group M (14 vs. 8 in groups M and L). Tourniquet was well tolerated in most patients with successful block in both groups. No serious complication was observed. Both the approaches were equivalent regarding success rate, tourniquet tolerance and safety. Coracoid approach seemed better as positioning of operative limb was less painful, coracoids process was easy to locate and the technique was easy to learn and master.

Nausea and vomiting after ENT surgeries: A comparison between ondansetron, metoclopramide and small dose of propofol.

AIMS: To evaluate the antiemetic efficacy of ondansetron, metoclopramide or small dose of propofol following ear, nose and throat (ENT) surgery. MATERIALS AND METHODS: A prospective randomized study involving 60 patients, both children and adults undergoing elective ENT surgery under standard general anesthesia. At the completion of surgery the patients received either 0.1 mg/kg of ondansetron or 0.2 mg/kg of metoclopramide or 0.5 mg/kg of propofol intravenously. The patients were observed for 24 hrs after operation for any occurrence of nausea and vomiting. RESULTS: The incidence of postoperative nausea and vomiting (PONV) during first 24 hrs was recorded in 20%, 70%, 50% of patients who had received ondansetron, metoclopr-amide or propofol respectively (p < 0.05). Fewer patients given ondansetron needed rescue antiemetic. The incidence of PONV was higher following middle year surgery. CONCLUSION: It was concluded that ondansetron was most effective in preventing occurrence of PONV while metoclopramide was least effective. Propofol was effective only in 50% of patients, thus not recommended for routine use.

Effect of preoperative gabapentin on postoperative pain and tramadol consumption after minilap open cholecystectomy: a randomized double-blind, placebo-controlled trial.

PURPOSE OF REVIEW: To evaluate the efficacy of a single preoperative dose of 600 mg of gabapentin for reducing postoperative pain and tramadol consumption after minilap open cholecystectomy. METHOD: A total of 120 adult patients of either sex were randomly assigned to receive 600 mg of gabapentin or a matched placebo orally 2 h before operation in a double-blind manner. All the patients received gabapentin using the same technique. Postoperative analgesia was provided with intravenous patient-controlled analgesia with tramadol using a 50-mg initial bolus dose, 20-mg incremental dose, 15-min lockout interval and 4-h limit of 240 mg. Patients were assessed at 0, 2, 4, 8, 12, 24 and 48 h after operation for verbal analogue pain scores at rest and at movement. Consumption of tramadol on first and second postoperative days and any adverse effects were also recorded. RESULTS: Verbal analogue pain scores were significantly lower on first postoperative day at all times of observation both at rest and at movement in gabapentin group than in placebo group (P<0.01). Tramadol consumption was also reduced by 33% in gabapentin group. But pain scores and tramadol consumption were similar in two groups on second postoperative day. Sedation was common but the incidence of postoperative nausea and vomiting was significantly lower in gabapentin group. CONCLUSION: Preoperative administration of 600 mg of gabapentin resulted in significant reduction in postoperative verbal analogue pain scores at rest and at movement as well as tramadol consumption compared with placebo on first postoperative day. Lower incidence of nausea and vomiting was an additional advantage. Sedation was the commonest side effect.