Cervical epidural analgesia combined with general anesthesia for head and neck cancer surgery: A randomized study.

BACKGROUND AND AIMS: The role of cervical epidural analgesia in head and neck cancer surgery is not fully explored. The aim of this study was to evaluate cervical epidural analgesia in terms of opioid and anesthetic requirements and stress response in patients undergoing head and neck cancer surgery. MATERIAL AND METHODS: After institutional ethical committee approval and written informed consent, 30 patients undergoing elective head and neck cancer surgery were randomized into two groups: Group E (cervical epidural analgesia with general anesthesia), and group G (general anesthesia alone). In group E, an 18 gauge epidural catheter was placed at cervical (C) 6 - thoracic (T) 1 level. After test dose, a bolus of 10 ml of 0.2% ropivacaine was given followed by continuous infusion. Technique of general anesthesia and post-operative management was standardized in both the groups. Opioid and anesthetic drug requirement was observed. Blood glucose and serum cortisol levels were measured at baseline; post-incision and after surgery. RESULTS: There was significant reduction in the requirement of morphine (P < 0.001), isoflurane (P = 0.004) and vecuronium (P = 0.001) in group E. Post-operative, blood glucose and serum cortisol levels were significantly reduced (P = 0.0153 and 0.0074, respectively). Early post-operative pain was reduced with the lesser requirement of post-operative morphine. CONCLUSIONS: The use of combined cervical epidural analgesia with general anesthesia reduces opioid, anesthetic drug requirement and stress response as compared to general anesthesia alone in patients undergoing head and neck cancer surgery.

A prospective survey on knowledge, attitude and current practices of pre-operative fasting amongst anaesthesiologists: A nationwide survey.

BACKGROUND AND AIMS: Pre-operative fasting is a routine practice to minimise the risk of pulmonary aspiration. The leading societies of anaesthesia have adopted more liberal fasting guidelines to avoid the adverse effect of prolonged fasting. This survey was conducted to assess the knowledge, attitude and current practice of fasting guidelines among Indian anaesthesiologists and to analyse the reasons for non-compliance of these guidelines. METHODS: A questionnaire consisted of 11 questions was distributed via 'Survey Monkey' software to 621 anaesthesiologists who attended the annual conference of the Indian Society of Anaesthesiologists held in Ludhiana, in 2016. American Society of Anaesthesiologists (ASA) practice guidelines for fasting were the standard of assessment. RESULTS: The response rate to the survey was 52%. Of the respondents, 69% described correctly the practice guidelines to pre-operative fasting. Only seven percent respondents were aware of the benefits of liberalised fasting. More than 2/3rd of the respondents advised fasting as per ASA guidelines during pre-anaesthetic check-up (PAC). However, only about 50% respondents confirmed that these guidelines are actually followed in their institution. Not having control on scheduling of cases in operation theatre and poor knowledge of ward nurses and surgeons were the common reasons for non-compliance of these guidelines. Twenty four percent respondents did not use routinely any drug for aspiration prophylaxis. CONCLUSION: Majority of the respondents were aware of the ASA fasting guidelines. However, the implementation of the guidelines and knowledge regarding benefits of liberalised fasting is poor among respondents.

Gabapentinoids as a Part of Multi-modal Drug Regime for Pain Relief following Laproscopic Cholecystectomy: A Randomized Study.

BACKGROUND: Gabapentinoids have been used as preemptive analgesics for pain management following laparoscopic cholecystectomy. Recently, multimodal analgesic techniques have been found superior to preemptive analgesia alone. AIM: The aim of this study is to evaluate and compare a single preoperative dose of pregabalin 150 mg and gabapentin 300 mg for pain relief following laparoscopic cholecystectomy as a part of multimodal drug regime. SETTINGS AND DESIGN: This randomized, single-blind study was conducted after Ethical Committee approval and written informed consent from the patients. MATERIALS AND METHODS: Fifty patients undergoing laparoscopic cholecystectomy under general anesthesia were randomly allocated to receive either 150 mg pregabalin (Group PG), or 300 mg gabapentin (Group GB) orally, 2 h before surgery. Standard anesthesia induction and maintenance were done. For intraoperative pain management, injection fentanyl 2 µg.kg-1 intravenous (IV) along with injection voveran 75 mg IV and port site infiltration was used. Postoperatively, injection diclofenac 75 mg intramuscular TDS was continued. Severity of postoperative pain (visual analog scale [VAS]), postoperative fentanyl requirement and incidence, and severity of side effects were assessed. When VAS >40 mm or on patient's request, a Fentanyl bolus at an increment of 25-50 µg IV was given as rescue analgesia. RESULTS: Intraoperative fentanyl requirement was 135 ± 14 µg in Group PG and 140 ± 14 µg in Group GB (P = 0.21). Postoperative, fentanyl requirement was 123 ± 18 µg in Group PG and 131 ± 23 µg in Group GB (P = 0.17) There was no statistically significant difference in the VAS score for static and dynamic pain. Time to the first requirement of analgesic was 5.4 ± 1.1 h in Group PG and 4.6 ± 1.6 h in Group GB (P = 0.015). No side effects were observed. CONCLUSION: We conclude that a single preoperative dose of pregabalin (150 mg) or gabapentin (300 mg) are equally efficacious in providing pain relief following laparoscopic cholecystectomy as a part of multimodal regime without any side effects.

Pregabalin in Monitored Anesthesia Care for Ear-nose-throat Surgery.

AIM: The aim of this study was to determine intraoperative sedative and perioperative analgesic requirement and associated side effects of pregabalin (150 mg) for monitored anesthesia care during ear-nose-throat (ENT) surgeries. MATERIALS AND METHODS: The study design was randomized and single-blinded; fifty patients undergoing elective ambulatory ENT surgeries under monitored anesthesia care were randomly allocated to receive either placebo (Group P) or pregabalin (Group PG) 150 mg, orally 1 h before surgery. All patients were then given intravenous (i.v.) midazolam 2 mg and fentanyl 1 µg/kg and local anesthesia at the site. Sedation was induced by administering an i.v. bolus of propofol 0.8 mg/kg and was maintained by continuous infusion of propofol. Level of sedation was assessed by Ramsay scale, and propofol infusion was titrated accordingly. Intraoperative pain was assessed by verbal rating scale (VRS) score. Patient having VRS >4 or complaint of pain was given fentanyl (0.5 µg/kg) i.v. bolus. Intraoperative sedative and analgesic requirement were recorded. Postoperative visual analog scale scores and requirement of analgesics were recorded for the first 24 h after surgery. Diclofenac 75 mg intramuscular (i.m.) was administered as rescue analgesic. Side effects (nausea/vomiting, sedation, dizziness, blurred vision) were also recorded. RESULTS: Intraoperative propofol (212 ± 11 mg vs. 174 ± 9 mg; P = 0.013) and fentanyl (120 ± 8 µg vs. 94 ± 6 µg; P = 0.02) consumption was significantly lower in Group PG. Time to first analgesic request was longer (6.1 ± 0.4 h vs. 9.5 ± 1.2 h) with lesser requirement of analgesics (diclofenac) in the postoperative period. Incidence of side effects (sedation, nausea, vomiting) was found to be similar in both the groups. CONCLUSION: Premedication with pregabalin (150 mg) reduces intraoperative sedative and perioperative analgesic requirement in patients undergoing ENT surgeries under monitored anesthesia care with tolerable side effects.

Postoperative analgesia in children: A comparison of three different doses of caudal epidural morphine.

BACKGROUND AND AIMS: Caudal epidural block is the most commonly used neuraxial block in children. Morphine has been used as a caudal additive for more than three decades. The aim of our study was to evaluate the efficacy and duration of analgesia of three different doses of caudal epidural morphine (CEM), and to find out the incidence of side effects. MATERIAL AND METHODS: This study was conducted on 75 patients of American Society of Anesthesiologists grades I and II, aged 2-12 years, undergoing lower abdominal and urogenital surgeries. Patients were randomly allocated to one of the three groups according to the dose of morphine. Group I received 30 µg/kg, group II 50 µg/kg, and group III 70 µg/kg. Heart rate, blood pressure, oxygen saturation, electrocardiogram, pain score, sedation score, duration of analgesia, and side-effects were noted. RESULTS: The mean duration of analgesia was 8.63 h in group I, 13.36 h in group II and 19.19 h in group III. Respiratory depression was noted in three patients in group III. One patient in group I had itching. One patient each in groups I, II, and III had nausea/vomiting. CONCLUSION: CEM significantly prolongs the duration of analgesia, though with a higher dose the risk of respiratory depression should always be kept in mind.

Brachial plexus block: Comparison of two different doses of clonidine added to bupivacaine.

BACKGROUND: The role of clonidine as an adjuvant to local anesthetic agents in brachial plexus block (BPB) has been extensively studied. However, till date there has been no consensus about the ideal dose of clonidine for this purpose. This study was carried out to evaluate two doses of clonidine-1 and 2 g/kg, added to 0.5% bupivacaine, with regard to onset and duration of sensorimotor blockade, hemodynamic effects, postoperative analgesia, and adverse effects. MATERIALS AND METHODS: Sixty adult patients undergoing upper limb surgeries were randomly allocated into two groups. Thirty patients received 1 g/kg clonidine (group I) and the rest received 2 g/kg clonidine (group II) added to 30 mL of 0.5% bupivacaine through nerve stimulator-guided supraclavicular BPB. The onset and duration of sensorimotor blockade, hemodynamic variables, duration of analgesia, level of sedation, and adverse effects was assessed. RESULTS: The onset of sensorimotor block was earlier in group II (9.9 ± 4.1 min for sensory block and 13.2 ± 6.7 min for motor block) than in group I (15.9 ± 6.8 min for sensory block and 18.5 ± 7.8 min for motor block). The duration of analgesia was also prolonged in patients receiving the higher dose (21.0 ± 2.96 h vs. 14.9 ± 3.0 h). Although hemodynamics remained comparable in both the groups, incidence of hypotension and bradycardia was higher in group II as compared to group I. The sedation was clinically and statistically more in group II patients (43% vs. 17%). CONCLUSION: Higher dose of clonidine in BPB hastens the onset, prolongs the duration of sensorimotor blockade and postoperative analgesia without significant hemodynamic alterations. It also causes more sedation, which although ensures patient comfort in most cases, but might be undesirable in certain situations.

A randomized controlled trial to compare fentanyl-propofol and ketamine-propofol combination for procedural sedation and analgesia in laparoscopic tubal ligation.

BACKGROUND: Procedural sedation and analgesia is widely being used for female laparoscopic sterilization using combinations of different drugs at varying doses. This study compared the combination of fentanyl and propofol, and ketamine and propofol in patients undergoing outpatient laparoscopic tubal ligation, with respect to their hemodynamic effects, postoperative recovery characteristics, duration of hospital stay, adverse effects, and patient comfort and acceptability. SETTINGS AND DESIGN: Randomized, double blind. METHODS: Patients were assigned to receive premixed injection of either fentanyl 1.5 µg/kg + propofol 2 mg/kg (Group PF, n=50) or ketamine 0.5 mg/kg + propofol 2 mg/kg (Group PK, n=50). Hemodynamic data, peripheral oxygen saturation, and respiratory rate were recorded perioperatively. Recovery time, time to discharge, and comfort score were noted. STATISTICAL ANALYSIS: Chi-square (χ(2)) test was used for categorical data. Student's t-test was used for quantitative variables for comparison between the two groups. For intragroup comparison, paired t-test was used. SPSS 14.0 was used for analysis. RESULTS: Although the heart rate was comparable, blood pressures were consistently higher in group PK. Postoperative nausea and vomiting and delay in voiding were more frequent in group PK (P<0.05). The time to reach Aldrete score ≥8 was significantly longer in group PK (11.14±3.29 min in group PF vs. 17.3±6.32 min in group PK, P<0.01). The time to discharge was significantly longer in group PK (105.8±13.07 min in group PF vs.138.18±13.20 min in group PK, P<0.01). Patient comfort and acceptability was better in group PF, P<0.01). CONCLUSION: As compared to ketamine-propofol, fentanyl-propofol combination is associated with faster recovery, earlier discharge, and better patient acceptability.

Foreign body esophagus in a neonate: Unusual age and unusual presentation.

Foreign body ingestion in neonatal period is an uncommon occurrence, despite foreign ingestion being common among pediatric age group. We report a rare case of foreign body esophagus in a 12-day-old female neonate causing obstructive symptoms after a homicidal attempt. The unusual age and circumstances involving the ingestion of the foreign body prompted us to report this case.

Methemoglobinemia as a result of accidental lacquer thinner poisoning.

Lacquer thinner, commonly used for removing household paints, is known to contain a mixture of various aromatic hydrocarbons, halogenated hydrocarbons and naptha; if ingested, it may cause methemoglobinemia. We report two cases who presented to us with a history of accidental ingestion of paint thinner. Both the patients had very high levels of methemoglobin and were treated with methylene blue (MB), but did not respond to the MB therapy. One of them received an exchange transfusion followed again by MB and survived. Unfortunately the other patient succumbed to the poisoning.

Preoperative predictors of mortality in adult patients with perforation peritonitis.

INTRODUCTION: There is paucity of data from India regarding the etiology, prognostic indicators, morbidity, and mortality patterns of perforation peritonitis. The objective of our study was to evaluate the predictors of mortality, preoperatively, for risk stratification of the patients and institution of an early goal-directed therapy. MATERIALS AND METHODS: Eighty-four consecutive patients presenting with perforation peritonitis, in the age group of 14-70 years scheduled for emergency laparotomy were studied prospectively. The parameters studied were age and sex of the patients, associated co-morbidities, duration of symptoms, delay in initiating surgical intervention, and preoperative biochemical parameters such as hemoglobin, random blood sugar, blood urea, serum creatinine, pH, base excess, and serum lactate levels. In-hospital mortality was taken as the outcome. RESULTS: We encountered a mortality of 17.8% in our study. Multiple linear (enter) regression identified the age, duration of symptoms, preoperative blood sugar levels, blood urea, serum creatinine levels, Mannheim Peritonitis Index, and the delay in instituting surgical intervention as independent predictors of mortality. Hyperlactatemia, acidosis and base excess were not found to be associated with mortality. CONCLUSION: Routine biochemical investigations, delay in presentation, and surgical intervention are good predictors of mortality. Recognizing such patients early may help the anesthesiologists in risk stratification and in providing an early goal-directed therapy.

Pneumothorax during laparoscopic repair of giant paraesophageal hernia.

Giant paraesophageal hernia is an uncommon morbid disorder which may present a risk of catastrophic complications and should be repaired electively as soon as possible. Laparoscopic fundoplication is the mainstay of surgical management of this disorder due to several advantages such as lower post-operative morbidity and pain. We report a case of a 70-year-old patient with a giant paraesophageal hernia, who developed subcutaneous emphysema with pneumothorax during laparoscopic fundoplication. Early diagnosis was possible by close clinical evaluation and simultaneous monitoring of end-tidal carbon dioxide levels and airway pressures. Although positive end-expiratory pressure application is an effective way of managing pneumothorax secondary to the passage of gas into the interpleural space, insertion of an intercostal drain may be used in an emergent situation.

Abnormal oculocardiac reflex in two patients with Marcus Gunn syndrome.

Marcus Gunn phenomenon is seen in 4 to 6% of congenital ptosis patients. We report two cases of abnormal oculocardiac reflex during ptosis correction surgery. Marcus Gunn syndrome is an autosomal dominant condition with incomplete penetrance. It is believed to be a neural misdirection syndrome in which fibres of the motor division of the trigeminal nerve are congenitally misdirected into the superior pterygoid and the levator muscles. Anesthetic considerations include taking a detailed history about any previous anaesthetic exposure and any reaction to it as this syndrome has a high probability of being associated with malignant hyperthermia. It is also postulated that an atypical oculocardiac reflex might be initiated in these patients as seen in our patients, so precautions must be taken for its prevention and early detection.

Randomized double-blind comparison of ketamine-propofol and fentanyl-propofol for the insertion of laryngeal mask airway in children.

BACKGROUND: Till date, different combinations of adjuncts with induction agents have been tried for Laryngeal Mask Airway (LMA) insertion; yet, the ideal combination that provides the best insertion conditions with minimal side effects has not been identified, particularly in children. PATIENTS #ENTITYSTARTX00026; METHODS: Hundred paediatric ASA grade I and II patients, aged 3-12 years, were randomly allocated to receive intravenously either fentanyl 2µg kg(-1) (Group F, n=50) or ketamine 0.5 mg kg(-1) (Group K, n=50), before induction of anaesthesia with propofol 3.5 mg kg(-1). Arterial blood pressure and heart rate were measured before induction (baseline), immediately before induction, immediately before LMA insertion, and at 1, 3 and 5 minutes after LMA insertion. Following LMA insertion, the following six subjective endpoints were graded by a blinded anaesthetist using ordinal scales graded 1 to 3: mouth opening, gagging, swallowing, head and limb movements, laryngospasm and resistance to insertion. Duration and incidence of apnoea was also recorded. RESULTS: The incidence of resistance to mouth opening, resistance to LMA insertion and incidence of swallowing was not statistically significant between the two groups. Coughing/ gagging was seen in 8% patients in group K as compared to 28% patients in group K. Limb/ head movements were observed in 64% patients in the fentanyl group and in 76% patients in the ketamine group. Laryngospasm was not seen in any patient in either group. Incidence of apnoea was 80% in the fentanyl group and 50% in the ketamine group. The heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were consistently higher in the ketamine group as compared to the fentanyl group. CONCLUSION: The combination of fentanyl (2µg kg-1) and propofol (3.5mg kg-1) provides better conditions for LMA insertion in children than a combination of ketamine (0.5 mg kg-1) and propofol (3.5mg kg-1).

Ambulatory laparoscopic tubal ligation: a comparison of general anaesthesia with local anaesthesia and sedation.

BACKGROUND: To compare the anaesthetic techniques for laparoscopic tubal ligation using either general anaesthesia with LMA or a combination of local anaesthetic and intravenous sedation, this study was conducted on 60 ASA-1/2 patients in the age group of 20-40 years. PATIENTS #ENTITYSTARTX00026; METHODS: 60 ASA grade I & II female patients undergoing laparoscopic tubal ligation on a day care basis were randomly divided in two groups- group I (GA using LMA, n=30), group II (Local anaesthesia, n=30). Both groups received similar premedication. General anaesthesia in group I was induced with propofol 2-3 mg kg(-1) and following LMA insertion, the anaesthesia was maintained with 0.5-1.5% halothane. In group II the incision site was infiltrated with 10 ml of 1.5% lidocaine with adrenaline and patients were sedated with intravenous midazolam 0.07mg kg(-1) and ketamine 0.5 mg kg(-1). A rescue dose of 0.15 mg kg(-1) of ketamine was given in group II if the patient complained of pain or discomfort during the procedure. Diclofenac sodium 1 mg kg(-1) was used for postoperative analgesia in both the groups. All patients were observed in the PACU until they met the discharge criteria. RESULTS: The demographic profile was similar in both the groups. The induction to skin incision time was significantly more in group I (5.13 ±0.93 min vs 3.01 ±1.86 min in group II). The decrease in pulse rate and blood pressure (systolic and diastolic) was also significant in group I. The incidence of intraoperative bradycardia was 16.7% and 10% in group I & group II respectively. The changes in SpO(2) during the procedure, recovery time and time to meet discharge criteria were comparable in both the groups. The incidence of PONV was 20% & 3.3% in group I and 10% & 6.6% in group II respectively. All patients in both the groups required postoperative analgesics. CONCLUSIONS: Both the techniques were found to be comparable for laparoscopic sterilization, however a longer induction to skin incision time and higher incidence of PONV and shivering in GA group makes LA with sedation a better choice.

Anaphylactic reaction to intravenous diclofenac.

Diclofenac sodium is a non-steroidal anti-inflammatory drug widely used as an opioid sparing agent for postoperative analgesia. Anaphylaxis due to intravenous diclofenac sodium is very rare. We report a case of anaphylactic reaction to IV diclofenac sodium, occurring postoperatively in a 25-year-old primigravida, the clinical features of which mimicked pulmonary embolism. The rarity, clinical importance and the diagnostic dilemma associated prompted us to report this case.

Efficacy of low-dose caudal clonidine in reduction of sevoflurane-induced agitation in children undergoing urogenital and lower limb surgery: a prospective randomised double-blind study.

BACKGROUND: Sevoflurane is commonly used as an inhalational induction agent in paediatric patients. Emergence agitation is a common post-operative problem in young children who have received sevoflurane. Clonidine has proven to be effective in reducing the incidence of post-operative agitation at a higher dose (3 and 2 µg kg⁻¹). It has some dose-dependent disadvantages, prominently bradycardia, hypotension and respiratory impairment. OBJECTIVE: The authors conducted a study to evaluate the effectiveness of low-dose caudal clonidine (1 µg kg⁻¹) in reducing the incidence of sevoflurane-induced agitation in preschool children undergoing urogenital and lower limb surgery. METHODOLOGY: A double-blind study was conducted comparing 0.25% (0.75 ml kg⁻¹) bupivacaine and clonidine 1 µg kg⁻¹ (group 1), 0.25% bupivacaine (0.75 ml kg⁻¹) and clonidine 0.75 µg kg⁻¹ (group 2), with 0.25% bupivacaine (0.75 ml kg⁻¹) alone (group 3). Ninety children of 1-5 years of American Society of Anesthesiologists I and II were randomly assigned into three groups. Post-operatively, patients were monitored for 1 h to observe emergence agitation, which was assessed with the help of Pain and Discomfort Scale. RESULT: Post-anaesthetic agitation was observed in two patients (6.6%) in group 1, eight patients (26.6%) in group 2 as compared to 12 patients (40%) in group 3 after 15 min of post-operative observation. The mean scores in group 1 at 15 and 30 min were significantly lower than those in group 3 (P value <0.05). None of the groups had showed any haemodynamic and respiratory compromise, either clinically and statistically. CONCLUSION: Caudal clonidine at a lower dose (1 µg kg⁻¹) could be effective in reducing the incidence of sevoflurane-induced emergence agitation in children undergoing urogenital and lower limb surgery without any significant adverse effects.

Subdural haematoma in pregnancy-induced idiopathic thrombocytopenia: Conservative management.

Conservative management of subdural haematoma with antioedema measures in second gravida with idiopathic thrombocytopenic purpura (ITP) resulted in resolution of haematoma. We present a case of second gravida with ITP who developed subdural haematoma following normal vaginal delivery. She was put on mechanical ventilation and managed conservatively with platelet transfusion, Mannitol 1g/kg, Dexamethasone 1mg/kg and Glycerol 10ml TDS. She regained consciousness and was extubated after 48 hrs. Repeat CT after 10 days showed no mass effect with resolving haematoma which resolved completely after 15 days. Trial of conservative management is safe in pregnant patient with ITP who develops subdural haematoma.