Safe and optimal pneumoperitoneal pressure for transperitoneal laparoscopic renal surgery in infant less than 10 kg, looked beyond intraoperative period: A prospective randomized study.

OBJECTIVE: A safe and optimal pneumoperitoneal pressure (PP) for laparoscopic renal surgery in infants is difficult to define. In a broad sense, a safe and optimal PP should cause least intraoperative and postoperative physiological stress for the infants and should be optimal for surgeon's technical feasibility. Unfortunately, the safe and optimal PP in infant for transperitoneal laparoscopic surgery has not been established by well validated study. To determine safe and optimal PP for laparoscopic renal surgery (LRS) in infants less than 10 kg. METHOD: In a prospective and randomized setting, between July 2008 and June 2014, 46 infants of <10 kg (Group I, n = 23, PP = 6-8 mmHg and Group II, n = 23, PP = 9-10 mmHg) who underwent LRS, were analyzed. Hemodynamic, respiratory, and blood gas changes were measured at four points: before CO2 insufflation (T0), 10 min after insufflation (T1), before desufflation (T2) and 10 min after desufflation (T3). Any required adjustments of ventilator parameters were noted. Time to resume feeding and postoperative pain at 1, 6, and 12 h, including requirement for postoperative rescue analgesia, were assessed. Technical feasibility with allocated PP was evaluated by means of successful completion of surgery, duration of surgery, and intraoperative complications. RESULTS: At T1 and T2, changes in hemodynamic and respiratory parameters were significantly higher in Group II. At T3, most of the parameters statistically restored back to baseline in Group I but not so in Group II. Required adjustments in ventilatory parameters were 14 vs. 25 times in Group I vs. Group II (p = 0.007, R = 0.552). Mean postoperative pain score, requirement for analgesia, and time to resume feeding were significantly greater in Group II. Surgeries were successfully completed in all the patients in both groups, with comparable duration of surgery and similar intraoperative complications (Table). CONCLUSION: It was found that hemodynamic and respiratory changes were more pronounced with higher pneumoperitoneal pressure in infants for renal laparoscopic surgery. With a PP of 6-8 mmHg, intraoperative accessibility is optimal, and physiological changes are minimal. Interestingly, we found that infants with PP of 6-8 mmHg enjoy smooth and early postoperative recovery. There was no direct objective criterion to assess level of difficulty with allocated PP, which may be considered a limitation of the present study. Pneumoperitoneal pressure of 6-8 mmHg appears to be a safe and optimal range for transperitoneal laparoscopic renal surgery in infants.

Vein pretreatment with magnesium sulfate to prevent pain on injection of propofol is not justified.

PURPOSE: Propofol produces anesthesia with rapid recovery. However, it causes pain or discomfort on injection. A number of techniques have been tried for minimizing propofol-induced pain with variable results. We have compared the efficacy of magnesium and lidocaine for the prevention of propofol induced pain. METHODS: Three hundred ASA I and II adults undergoing elective surgery were randomly assigned into three groups of 100 each. Group I received magnesium sulfate 1 g, Group II received lidocaine 2% (40 mg) and Group III received normal saline, all in a volume of 2 mL and accompanied by venous occlusion for one minute. Induction with propofol 2.5 mg.kg(-1) was accomplished following the release of venous occlusion. Pain was assessed on a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain at the time of pretreatment and propofol injection. Results were analyzed by 'Z' test. A P value of < 0.05 was considered as significant. RESULTS: Pain during i.v. pretreatment with magnesium was 31% as compared to 2% for both the lidocaine and control groups (P < 0.05). Seventy-six percent of patients in the control group had pain during i.v. propofol as compared to 32% and 42% in the magnesium and the lidocaine groups respectively (P < 0.05). Lidocaine and magnesium pretreatment were equally effective in attenuating pain during the propofol injection (P > 0.05). CONCLUSIONS: Intravenous magnesium and lidocaine pretreatment are equally effective in attenuating propofol-induced pain. However, magnesium pretreatment itself causes pain. Therefore, there is no justification in the use of magnesium pretreatment for attenuating pain associated with i.v. propofol.

Pretreatment with thiopental for prevention of pain associated with propofol injection.

UNLABELLED: Propofol causes pain on IV injection in 28%-90% of patients. A number of techniques have been tried to minimize propofol-induced pain, with variable results. We compared the efficacy of pretreatment with thiopental 0.25 mg/kg and 0.5 mg/kg and lidocaine 40 mg after venous occlusion for prevention of propofol-induced pain. One-hundred-twenty-four adult patients, ASA physical status I-II, undergoing elective surgery were randomly assigned into 4 groups of 31 each. Group I received normal saline, group II received lidocaine 2% (40 mg), and groups III and IV received thiopental 0.25 mg/kg and 0.5 mg/kg, respectively. All pretreatment drugs were made in 2 mL and were accompanied by manual venous occlusion for 1 min. Propofol was administered after release of venous occlusion. Pain was assessed with a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain at the time of propofol injection. Twenty-four patients (77%) complained of pain in the group pretreated with normal saline as compared with 12 (39%), 10 (32%), and 1 (3%) in the groups pretreated with lidocaine 40 mg, thiopental 0.25 mg/kg, and thiopental 0.5 mg/kg, respectively (P < 0.05). Thiopental 0.5 mg/kg was the most effective treatment. We therefore suggest routine pretreatment with thiopental 0.5 mg/kg along with venous occlusion for 1 min for prevention of pain associated with propofol injection. IMPLICATIONS: Pain associated with IV injection of propofol is seen in 28%-90% patients. Pretreatment with thiopental 0.25 mg/kg and 0.5 mg/kg after manual venous occlusion for 1 min effectively attenuated pain associated with propofol injection. Thiopental 0.5 mg/kg was the most effective in prevention of propofol pain and can be used routinely.

Salbutamol, beclomethasone or sodium chromoglycate suppress coughing induced by iv fentanyl.

PURPOSE: Fentanyl, a synthetic opioid, is a popular choice amongst anesthesiologists in the operating room. Preinduction iv fentanyl bolus is associated with coughing in 28-45% of patients. Coughing due to fentanyl is not always benign and at times may be explosive requiring immediate intervention. We have studied the role of aerosol inhalation of salbutamol, beclomethasone and sodium chromoglycate in preventing fentanyl induced coughing and have compared their efficacy. METHODS: Two hundred patients aged 18-60 yr, undergoing elective laparoscopic cholecystectomy were randomized into four groups of 50 each. Group I served as control, while Groups II, III and IV received an aerosol inhalation of salbutamol, beclomethasone or sodium chromoglycate 15 min prior to entering the operating room. Following iv fentanyl (2 micro g x kg(-1)) the incidence of cough was recorded and graded as mild (1-2), moderate (3-5) and severe (> 5) depending on the number of coughs observed. Results were analyzed using 'z' and Fischer's Exact test. A P value of < or = 0.05 was considered significant. RESULTS: The incidence of cough was 28% in the control group, 6%, 0% and 4% in the salbutamol, beclomethasone and sodium chromoglycate groups respectively. Occurrence of cough was significantly low (P < or = 0.05) in the treatment groups, however the difference amongst the groups was not significant (P >/= 0.05). CONCLUSION: The use of salbutamol, beclomethasone or sodium chromoglycate aerosol 15 min prior to iv fentanyl administration minimizes fentanyl-induced coughing.

Oxygen in air (FiO2 0.4) improves gas exchange in young healthy patients during general anesthesia.

PURPOSE: One hundred percent O(2) is used routinely for preoxygenation and induction of anesthesia. The higher the O(2) concentration the faster is the development of atelectasis, an important cause of impaired pulmonary gas exchange during general anesthesia (GA). We evaluated the effect of ventilation with 0.4 FiO(2) in air, 0.4 FiO(2) in N(2)O and 100% O(2) following intubation on the development of impaired gas exchange. METHODS: Twenty-seven patients aged 18-40 yr, undergoing elective laparoscopic cholecystectomy were administered 100% O(2) for preoxygenation (three minutes) and ventilation by mask (two minutes). Following intubation these patients were randomly divided into three groups of nine each and ventilated either with 0.4 FiO(2) in air, 0.4 FiO(2) in N(2)O or 100% O(2). Arterial blood gases were obtained before preoxygenation and 30 min following intubation for PaO(2) analysis. Subsequently PaO(2)/FiO(2) ratios were calculated. Results were analyzed with Student's t test and one-way ANOVA. P value of < or = 0.05 was considered significant. RESULTS: Ventilation of the lungs with O(2) in air (FiO(2) 0.4) significantly improved the PaO(2)/FiO(2) ratio from baseline, while 0.4 FiO(2) in N(2)O or 100% O(2) worsened the ratio (558 +/- 47 vs 472 +/- 28, 365 +/- 34 vs 472 +/- 22 and 351 +/- 23 vs 477 +/- 28 respectively; P < 0.05). CONCLUSION: Ventilation of lungs with O(2) in air (FiO(2) 0.4) improves gas exchange in young healthy patients during GA.