Does the objective measurement of muscle strength improve the detection of postoperative residual muscle weakness?

Background and Aims: The postoperative residual neuromuscular block (PRNB) has a significant impact on patient safety and well-being, but continues to remain underestimated. Objective evaluation of handgrip strength using a force dynamometer can be useful to identify postoperative muscle weakness. Material and Methods: Thirty-two American Society of Anesthesiologists (ASA) class I and II patients who received general anesthesia were included. Patients were extubated after the train-of-four (TOR) ratio (TOFR) was >0.90 and the clinical criteria for motor power recovery were judged as adequate. The measurements of handgrip strength and peak expiratory flow rate (PEFR) were obtained at baseline, 15 min after extubation, and 1, 2, and 4 h postoperatively. The incidence of significant decline from baseline (>25%) was determined. The correlation between handgrip strength and PEFR was assessed using Spearman correlation. The time to return to baseline for muscle grip strength and PEFR was performed using Kaplan-Meier survival analysis. A P value of 0.05 was considered significant for all tests. Results: The incidence of the significant decline in handgrip strength from baseline was 100% at 15 and 60 min, 76% at 2 h, and 9.4% at 4 h. There was a strong correlation between muscle grip strength and PEFR (0.89, P < 0.001). None of the patients exhibited the potential complications of PRNB. (PRMB in abstract. It should be uniform) The mean time to return to the baseline value of muscle grip strength was 3.8 h (95% confidence interval [CI] 3.6-3.9), and the mean time to return to baseline for PEFR was 3.2 h (95% CI 2.9-3.4 h). Conclusion: Objective assessment of muscle grip strength using a force dynamometer has the potential to be a new objective metric to monitor postoperative muscle weakness.

Chronic pain following thoracotomy for lung surgeries: It's risk factors, prevalence, and impact on quality of life - A retrospective study.

BACKGROUND AND AIMS: Chronic post thoracotomy pain (CPTP) is a nagging complication and can affect quality of life (QOL). Studies conducted across globe have found a wide variability in the risk factors predisposing to chronic pain following thoracotomy. As no study on CPTP is available from India, we aim to detect the prevalence of CPTP, assess the predisposing factors implicated in its causation and study the impact of CPTP on QOL. METHODS: After obtaining clearance from Institutional ethics committee, medical records of patients who underwent open posterolateral thoracotomy between January 2012 and December 2015 were reviewed. Data on perioperative variables, address, and contact number were collected from the patient records. All patients were mailed the Telugu translation of medical outcome study short form -36(MOS-SF-36) QOL questionnaire and were contacted telephonically to enquire about presence of CPTP and QOL. A univariate analysis was done to assess factors associated with CPTP and a multivariate logistic regression analysis was done subsequently to identify independent risk factors of CPTP. QOL indices were compared between those patients who suffered from CPTP and those who did not. RESULTS: The prevalence of pain in our study was 40.86% (85/208). The factors implicated in the causation of CPTP were diabetes mellitus, preoperative pain, rib resection, and duration of chest tube drainage with odds ratio of 9.8, 2.6, 6.7, and 1.03, respectively. The health-related QOL showed poor scores in all domains in patients suffering from CPTP. CONCLUSION: The prevalence of CPTP was high. It significantly impacts health-related QOL.

Complex pseudoaneurysm of ascending aorta: Unusual cause of right heart dysfunction-implications to the anesthesiologist.

Pseudoaneurysm of ascending aorta (PAA) is a rare complication occurring after cardiac surgery. Because of rarity of the condition, most standard teaching and anesthetic literature do not highlight on these postoperative aortic complications. Right heart dysfunction associated with PAA is scarcely reported. We describe here two cases of PAA with right heart involvement and discuss the possible anesthetic challenges.

Does Parsonnet scoring model predict mortality following adult cardiac surgery in India?

AIMS AND OBJECTIVES: To validate the Parsonnet scoring model to predict mortality following adult cardiac surgery in Indian scenario. MATERIALS AND METHODS: A total of 889 consecutive patients undergoing adult cardiac surgery between January 2010 and April 2011 were included in the study. The Parsonnet score was determined for each patient and its predictive ability for in-hospital mortality was evaluated. The validation of Parsonnet score was performed for the total data and separately for the sub-groups coronary artery bypass grafting (CABG), valve surgery and combined procedures (CABG with valve surgery). The model calibration was performed using Hosmer-Lemeshow goodness of fit test and receiver operating characteristics (ROC) analysis for discrimination. Independent predictors of mortality were assessed from the variables used in the Parsonnet score by multivariate regression analysis. RESULTS: The overall mortality was 6.3% (56 patients), 7.1% (34 patients) for CABG, 4.3% (16 patients) for valve surgery and 16.2% (6 patients) for combined procedures. The Hosmer-Lemeshow statistic was <0.05 for the total data and also within the sub-groups suggesting that the predicted outcome using Parsonnet score did not match the observed outcome. The area under the ROC curve for the total data was 0.699 (95% confidence interval 0.62-0.77) and when tested separately, it was 0.73 (0.64-0.81) for CABG, 0.79 (0.63-0.92) for valve surgery (good discriminatory ability) and only 0.55 (0.26-0.83) for combined procedures. The independent predictors of mortality determined for the total data were low ejection fraction (odds ratio [OR] - 1.7), preoperative intra-aortic balloon pump (OR - 10.7), combined procedures (OR - 5.1), dialysis dependency (OR - 23.4), and re-operation (OR - 9.4). CONCLUSIONS: The Parsonnet score yielded a good predictive value for valve surgeries, moderate predictive value for the total data and for CABG and poor predictive value for combined procedures.

Dose sparing of induction dose of propofol by fentanyl and butorphanol: A comparison based on entropy analysis.

BACKGROUND: The induction dose of propofol is reduced with concomitant use of opioids as a result of a possible synergistic action. AIM AND OBJECTIVES: The present study compared the effect of fentanyl and two doses of butorphanol pre-treatment on the induction dose of propofol, with specific emphasis on entropy. METHODS: Three groups of 40 patients each, of the American Society of Anaesthesiologistsphysical status I and II, were randomized to receive fentanyl 2 µg/kg (Group F), butorphanol 20 µg/kg (Group B 20) or 40 µg/kg (Group B 40) as pre-treatment. Five minutes later, the degree of sedation was assessed by the observer's assessment of alertness scale (OAA/S). Induction of anesthesia was done with propofol (30 mg/10 s) till the loss of response to verbal commands. Thereafter, rocuronium 1 mg/kg was administered and endotracheal intubation was performed 2 min later. OAA/S, propofol induction dose, heart rate, blood pressure, oxygen saturation and entropy (response and state) were compared in the three groups. STATISTICAL ANALYSIS: Data was analyzed using ANOVA test with posthoc significance, Kruskal-Wallis test, Chi-square test and Fischer exact test. A P<0.05 was considered as significant. RESULTS: The induction dose of propofol (mg/kg) was observed to be 1.1±0.50 in Group F, 1.05±0.35 in Group B 20 and 1.18±0.41 in Group B40. Induction with propofol occurred at higher entropy values on pre-treatment with both fentanyl as well as butorphanol. Hemodynamic variables were comparable in all the three groups. CONCLUSION: Butorphanol 20 µg/kg and 40 µg/kg reduce the induction requirement of propofol, comparable to that of fentanyl 2 µg/kg, and confer hemodynamic stability at induction and intubation.