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BACKGROUND AND AIMS: Pain of open thoracotomy is treated with systemic analgesics, thoracic epidural and paravertebral blocks which have associated adverse effects and complications. Research shows ultrasound guided erector spinae plane block (US-ESPB) as a simpler and safer alternative. As paucity of data of US-ESPB in paediatric thoracotomies exists. We aimed at studying the analgesic efficacy of US-ESPB for paediatric thoracotomy. METHODS: In a prospective observational study, 30 children, 1-12 years age undergoing thoracotomy with decortication under general anaesthesia with US-ESPB were observed. At induction, patient received intravenous (IV) fentanyl 3 µg/kg for analgesia and standard general endotracheal anaesthesia was administered. US-ESPB was given at fourth thoracic vertebral level with 0.25% bupivacaine 0.3 ml/kg. Changes in haemodynamic parameters at skin incision, rib retraction, pleural incision, intercostal drain insertion, and skin closure were noted. Intraoperatively, additional fentanyl was administered, if required and its dose and time were noted. Postoperative pain was assessed by visual analogue scale (VAS) (0-10) for ≥6 years and by face, leg, activity, cry, consolability (FLACC) score (0-10) for <6 years at post extubation, 30 minutes and hourly postoperatively. Descriptive statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 20. RESULTS: Additional analgesic was not required in 14/30 patients (46.67%) intraoperatively and within 6 hours (7.4 ± 1.26) post-operatively. Five of the remaining 16 patients, required IV 1 µg/kg fentanyl only once intraoperatively. Median pain score was 2 in first four postoperative hours. CONCLUSION: US-ESPB provided effective supplemental intraoperative and postoperative analgesia in nearly half of the paediatric thoracotomy patients.
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BACKGROUND AND AIMS: Risk stratification of severely morbid obstetric patients receiving anaesthesia services can be helpful in improving maternal outcomes. This study was undertaken to analyse these patients using the WHO near-miss (NM) approach and to assess the applicability of maternal severity score (MSS) to predict maternal mortality. METHODOLOGY: This is a one-year retrospective cohort analysis at a tertiary care centre. Of all the obstetric patients receiving anaesthesia, those with 'potentially life-threatening conditions' (PLTC) were identified. Amongst women with PLTC, those fulfilling the WHO NM criteria were grouped into either maternal near miss (MNM) or maternal death (MD) depending on final survival outcome. The MSS was assessed upon admission to post-anaesthesia ICU. The cases of "near miss" were compared to maternal death to determine the factors and WHO NM criteria significantly associated with mortality. Area under ROC curve (AUROC) was used to assess the accuracy of MSS to predict maternal mortality. RESULTS: Of the 4351 anaesthetised obstetric patients, 301 were PLTC, 59 MNM and 11 MD. Obstetric haemorrhage was the commonest PLTC with the highest risk for MNM and MD. Preoperative organ dysfunction, referral from other centres, intra-uterine fetal death (IUFD) and WHO cardiovascular and respiratory NM criteria were significantly associated with mortality. MSS had excellent accuracy for the prediction of mortality (AUROC was 0.986 and 95% CI 0.966-0.996). CONCLUSION: Haemorrhage is the leading cause of MNM and MD. MSS is reliable in stratifying the severity of maternal morbidity and in predicting maternal mortality. Thus it can be used as an effective prognostic tool.
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BACKGROUND AND AIMS: Supraglottic airways (SGAs) should have good oropharyngeal seal pressures (OSP) for adequate ventilation and prevention of aspiration. Our aim was to study the effect of lateral position on OSP and thereby on ventilatory parameters for i-gel® and ProSeal™ laryngeal mask airway (PLMA) in children. METHODS: In this prospective observational study, 86 children of ASA I-II, aged 1 month to 12 years, scheduled for elective surgery under general anaesthesia using i-gel® or PLMA and requiring lateral position either for surgery or regional blocks were included. In both supine and lateral position OSP (constant flow method), expired tidal volume, fractional volume loss (%), and end-tidal carbon dioxide (ETCO2) were noted. Intragroup and intergroup difference in OSP from supine to lateral position was analyzed using paired and unpaired t-test respectively. RESULTS: In lateral position, there was a significant decrease in the OSP (cm H2O) in both i-gel® (supine: 21.94 ± 5.82, lateral: 15.54 ± 5.37) and PLMA (supine: 17.53 ± 5.05, lateral: 12.76 ± 3.37) groups (P = 0.000). Percentage reduction in OSP from supine to lateral with i-gel® (28.14 ± 18.86) and PLMA (24.06 ± 19.75) were comparable (P = 0.339). With both i-gel® and PLMA significant increase in fractional volume loss and ETCO2 were noted in lateral position. I-gel® group had higher OSP compared to PLMA in supine (P = 0.001) and lateral position (P = 0.009). CONCLUSION: In lateral position there was significant reduction in OSP compared to supine position with both i-gel® and PLMA.
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BACKGROUND AND AIMS: We studied the efficacy and safety of different total intravenous anesthesia used for pediatric magnetic resonance imaging (MRI). MATERIAL AND METHODS: Children of 1-7 years age (n = 88), undergoing MRI received a loading dose of dexmedetomidine 1 µg/kg over 10 min, ketamine 1 mg/kg, and propofol 1 mg/kg in sequence. University of Michigan Sedation Scale (UMSS) of 3 was considered an acceptable level for starting the scan. Rescue ketamine 0.25-0.5 mg/kg was given if UMSS remained <3. After the loading dose of drugs, some children attained UMSS = 4 or progressive decline in heart rate, therefore, did not receive any infusion. The rest received either dexmedetomidine (0.7 µg/kg/h) (n = 35) or propofol (3 mg/kg/h) (n = 38) infusion for maintenance. Ketamine 0.25 mg/kg was used as rescue. Sedation failure was considered if either there was inability to complete the scan at the pre-set infusion rate, or there was need for >3 ketamine boluses or serious adverse events occurred. Statistical Package for Social Sciences 20 was used for analysis. RESULTS: Initiation of scan was 100% successful with median induction time of 10 min. Maintenance of sedation was successful in 100% with dexmedetomidine and 97.4% with propofol infusion. Recovery time (25 min v/s 30 min), discharge time (35 min v/s 60 min), and total care duration (80 min v/s 105 min) were significantly less with propofol as compared to dexmedetomidine (P = 0.002, 0.000, and 0.000, respectively). There were no significant adverse events observed. CONCLUSION: Dexmedetomidine 1µg/kg, ketamine 1 mg/kg, and propofol 1 mg/kg provide good conditions for initiation of MRI. Although dexmedetomidine at 0.7µg/kg/h and propofol at 3 mg/kg/h are safe and effective for maintenance, propofol provides faster recovery.
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BACKGROUND AND AIMS: Supraglottic airway devices (SGADs) are increasingly being used for airway management in paediatric patients undergoing general anaesthesia. This survey was designed to assess the nationwide practice patterns of SGAD usage in paediatric patients. METHODS: A questionnaire of 28 questions was circulated amongst 16,532 members of the Indian Society of Anaesthesiologists through online survey engine Google Forms® and served manually to 500 delegates attending the Asian Society of Paediatric Anaesthesiologists conference 2017. Percentage, mean and standard deviation were calculated using Microsoft Excel 2016 (Redmond, WA, USA). RESULTS: Four hundred and five (2.3%) valid responses were obtained. The most commonly used device was i-gel© (60.74%). Three hundred and four (75.06%) respondents had access to second-generation SGADs. Second-generation devices (60.74%) were more commonly used than first-generation devices (39.26%). Anaesthesiologists utilised SGADs in various challenging scenarios such as in the difficult airway (53.33%), remote locations (55.47%), ophthalmologic (38.77%) and long-duration surgeries (17.53%). Sixty per cent respondents did not use SGADs in laparoscopic surgery. Disposable SGADs were reused by 77.28% respondents. Oropharyngeal seal and intracuff pressures were not measured by 86.91% and 56.92% respondents, respectively. Difficulty in size selection (84.19%), securing position (82.22%) and maintaining unobstructed ventilation (78.76%) were common problems encountered while using SGADs. CONCLUSION: Although there is a widespread use of second-generation SGADs in Indian paediatric anaesthesia, safe practices such as using capnography, measurement of oropharyngeal seal pressure, cuff pressure and appropriate disinfection are lacking.
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BACKGROUND AND AIMS: Propofol injection pain is an unresolved problem in children. Although medium and long chain triglyceride (MCT-LCT) propofol has shown promising results in adults, its efficacy in children is not proven. In a prospective observational study the incidence and severity of pain with MCT-LCT and LCT propofol in children was compared. METHODS: After obtaining approval from the Institutional Ethics Committee, 170 children (age group 6 months to 8 years) scheduled for various surgeries were included in this study. Following standard pre-medication, propofol 1% either LCT or MCT-LCT in a dose of 2-4 mg/kg along with preservative-free lignocaine (2% lignocaine 1 mg in propofol 10 mg) was administered. The primary objective was to study injection pain on scale of 0-6. For children ≤2 years doubling of motor event score (0-3) and for children >2 years, addition of motor (0-3) and verbalisation scores (0-3) were considered. Mann-Whitney U test was used for statistical analysis. RESULTS: MCT-LCT group had lower incidence of pain (17 patients (20%) versus 35 patients (35.3%), P = 0.026) and severe pain (zero patients (0%) versus six patients (7.1%), P = 0.029) as compared to LCT group. MCT-LCT group had significantly lower mean rank of motor (79.65 versus 91.35), verbal (77.29 versus 90.79) and total score (77.76 versus 93.24) as compared to LCT group (P = 0.037, 0.002, and 0.009, respectively). CONCLUSION: MCT-LCT propofol is associated with significantly lower injection pain as compared to LCT propofol in children, when both are combined with lignocaine.
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BACKGROUND AND AIMS: Increasing number of pediatric ambulatory surgeries are being carried out in general anesthesia using supraglottic airways (SGAs). Literature comparing sevoflurane and desflurane for the maintenance of SGA-based anesthesia is limited. Hence, we planned this prospective randomized study to compare the maintenance, emergence and recovery characteristics of sevoflurane and desflurane for pediatric ambulatory surgery. MATERIAL AND METHODS: Sixty children aged 6 months to 6 years posted for short surgical procedures were enrolled into the study. Anesthesia was induced with intravenous propofol (maximum 4 mg/kg), SGA was inserted, and children were randomized to receive sevoflurane or desflurane for the maintenance of anesthesia. No muscle relaxants were administered, and all children received caudal block and rectal paracetamol suppository. Demographic data, perioperative hemodynamics and adverse events, emergence and recovery characteristics, postoperative pain, and emergence agitation (EA) were recorded. Data were analyzed using SPSS (version 16.0, IBM Corporation, Armonk, New York, USA). P < 0.05 was considered statistically significant. RESULTS: Demography, perioperative hemodynamics, and duration of inhalational anesthesia were comparable between two groups. There were no respiratory adverse events in either group during maintenance. Time to awakening and time to removal of SGA were shorter with desflurane (5.3 ± 1.4 and 5.8 ± 1.3 min) than sevoflurane (9.1 ± 2.4 and 10.0 ± 1.6 min) (P < 0.0001). Recovery (steward recovery score = 6) was faster with desflurane (18 ± 8.4 min) than sevoflurane (45.3 ± 9.7 min) (P < 0.001). The incidence of EA was 16.7% with desflurane and 10% with sevoflurane (P = 0.226). CONCLUSION: Desflurane provides faster emergence and recovery in comparison to sevoflurane when used for the maintenance of anesthesia through SGA in children. Both sevoflurane and desflurane can be safely used in children for lower abdominal surgeries.
