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   2011| October-December  | Volume 27 | Issue 4  
    Online since October 24, 2011

 
 
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EDITORIALS
Anesthesia : Contributing to pollution?
Rakhee Goyal, Mukul Chandra Kapoor
October-December 2011, 27(4):435-437
DOI:10.4103/0970-9185.86565  PMID:22096272
  4,424 10,197 3
REVIEW ARTICLES
Psychiatric diseases: Need for an increased awareness among the anesthesiologists
Sukhminder Jit Singh Bajwa, Ravi Jindal, Jasbir Kaur, Amarjit Singh
October-December 2011, 27(4):440-446
DOI:10.4103/0970-9185.86572  PMID:22096274
Psychological disorders and psychiatric diseases have been on the rise since the last three decades. An increasing number of such patients are encountered nowadays for elective or emergency surgery. A multi-array of challenges are faced while anesthetizing these patients or treating them in an intensive care unit. The problems include the deteriorated mental physiology, altered cognition and the possible drug interactions with psychotropic medications. The challenge starts from the preoperative assessment stage. Knowledge of the pharmacological profile of the various anti-psychotic drugs, their side-effects and drug interactions are of prime importance for an anesthesiologist to facilitate smooth delivery of anesthesia in such patients. It is important to formulate a clear plan to deal with any challenge in the perioperative or postoperative period. All the clinical aspects and various definitions of mental disorders in the present article have been used as per the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). We reviewed the advances in psychiatric diseases, their treatment and their implications on delivery of anesthesia.
  9,328 2,586 3
A systematic review of the effects of sedatives and anesthetics in patients with obstructive sleep apnea
Saravanan Ankichetty, Jean Wong, Frances Chung
October-December 2011, 27(4):447-458
DOI:10.4103/0970-9185.86574  PMID:22096275
The objective of this review is to determine the effects of perioperative sedatives and anesthetics in surgical patients with obstructive sleep apnea (OSA) on respiratory events, medication requirements, hemodynamics, pain, emergence, and hospital stay. We searched The Cochrane CENTRAL Register of Controlled Trials, Medline, Embase, and Cochrane Database of Systematic Reviews from 1950 to June 2010 for relevant articles. All prospective and retrospective studies were eligible for inclusion if the effects of perioperative administration of sedation and anesthetics on medication requirements, pain, emergence, hemodynamics, respiratory events, and length of hospital stay in OSA patients were reported. T0 he search strategy yielded 18 studies of 1467 patients. Of these, 456 patients were documented as having OSA. Few adverse respiratory effects were reported. Eight out of 700 (1.14%) patients undergoing middle ear surgery with midazolam and fentanyl had impaired upper airway patency and were retrospectively diagnosed as having OSA by polysomnography. Also, intraoperative snoring causing uvular edema in the postoperative period was described in an OSA patient undergoing upper limb surgery when propofol was administered with midazolam and fentanyl for sedation. A decrease in oxygen saturation in the postoperative period was described with propofol and isoflurane in 21 OSA patients undergoing uvulo-palato-pharyngoplasty and tonsillectomy surgery (P<0.05). Perioperative alpha 2 agonists were shown to decrease the use of anesthetics (P<0.05), analgesics (P=0.008) and anti-hypertensives (P<0.001) in OSA patients. Contradictory reports regarding emergence occurred with intraoperative dexmedetomidine. Intraoperative opioids decreased the analgesic consumption (P=0.03) and pain scores (P<0.05) in the postoperative period. There was limited data on the length of hospital stay. There were few adverse effects reported when patients with known OSA underwent elective surgery with the currently available sedatives and anesthetics. Adverse events were reported with midazolam. However, the quality and number of patients in the studies were limited. There is a need for further trials with large numbers and uniform reporting of outcomes.
  9,260 2,283 36
ORIGINAL ARTICLES
Comparative study of intrathecal dexmedetomidine with intrathecal magnesium sulfate used as adjuvants to bupivacaine
Deepika Shukla, Anil Verma, Apurva Agarwal, HD Pandey, Chitra Tyagi
October-December 2011, 27(4):495-499
DOI:10.4103/0970-9185.86594  PMID:22096283
Background : No drug, used as adjuvant to spinal bupivacaine, has yet been identified that specifically inhibits nociception without its associated side-effects. Aims : This prospective randomized double-blind study was conducted to evaluate the onset and duration of sensory and motor block as well as perioperative analgesia and adverse effects of dexmedetomidine and magnesium sulfate given intrathecally with 0.5% hyperbaric bupivacaine for spinal anesthesia. Materials and Methods : A total of 90 patients classified as American Society of Anesthesiologists status I and II scheduled for lower abdominal and lower limb procedures were prospectively studied. Patients were randomly allocated to receive intrathecally either 15 mg hyperbaric bupivacaine plus 0.1 ml (10 μg) dexmedetomidine (group D, n=30) or 15 mg hyperbaric bupivacaine plus 0.1 ml (50 mg) magnesium sulfate (group M, n=30) or 15 mg hyperbaric bupivacaine plus 0.1 ml saline (group C, n=30) as control. The onset time to reach peak sensory and motor level, the regression time for sensory and motor block, hemodynamic changes and side-effects were recorded. Statistical Analysis Used : All statistical analyses were performed using INSTAT for windows. Continuous variables were tested for normal distribution by the Kolmogorov-Smirnov test. Data was expressed as either mean and standard deviation or numbers and percentages. Continuous covariates (age, body mass index and height) were compared using analysis of variance (ANOVA). For the times to reach T10 dermatomes, Bromage 3 scale and the regression of the sensory block to S1 dermatome and Bromage scale 0, one-way ANOVA was used to compare the means. The level of significance used was P<0.05. Results : The onset times to reach T10 dermatome and to reach peak sensory level as well as onset time to reach modified Bromage 3 motor block were significantly different in the three groups. The onset time to reach peak sensory and motor level was shorter in group D as compared with the control group C, and it was significantly prolonged in group M. We also found that patients in group D had significant longer sensory and motor block times than patients in group M, which was greater than in the control group C. Conclusion : It was found that onset of anesthesia was rapid and of prolonged duration in the dexmedetomidine group (D). However, in the magnesium sulfate group (M), although onset of block was delayed, the duration was significantly prolonged as compared with the control group (C), but to a lesser degree than in the dexmedetomidine group (D). The groups were similar with respect to hemodynamic variables and there were no significant side-effects in either of the groups.
  8,271 1,685 41
LETTERS TO THE EDITOR
An assembly to allow nebulization and oxygen enrichment of spontaneously breathing tracheostomized patients on T-piece
Kapil Chaudhary, Rakesh Kumar, Sunil Kumar, Neera Rani Gupta
October-December 2011, 27(4):569-570
DOI:10.4103/0970-9185.86616  PMID:22096305
  7,770 344 -
ORIGINAL ARTICLES
Preventive analgesia: Effect of small dose of ketamine on morphine requirement after renal surgery
Beena Parikh, Jyotsna Maliwad, Veena R Shah
October-December 2011, 27(4):485-488
DOI:10.4103/0970-9185.86592  PMID:22096281
Background : N-methyl D-Aspartate (NMDA) receptors seem to be responsible for pain memory and their blockade can contribute significantly in prevention of pain. This study was conducted to evaluate the preventive effect of small dose of ketamine, a NMDA receptor blocker, given before skin incision in renal surgery, with the aim to compare analgesic efficacy, intra operative and post-operative side effects. Materials and Methods : In a prospective double-blind study, 60 American Society of Anesthesiologists (ASA) risk I and II adult patients scheduled for elective open renal surgeries by flank incision were randomly divided in two groups. Ketamine group (group K) received ketamine 0.15 mg/kg intravenously, 30 minute before start of surgery followed by infusion of ketamine 2 mcg/kg/min till start of skin closure. Control group (group C) received normal saline in place of ketamine. Both groups received morphine 0.15 mg/ kg i.v. at the time of skin closure. The analgesic efficacy was judged by visual analogue scale (VAS) at rest and on movement, time to first analgesic and morphine consumption in 24 hours. Opioid or ketamine related side effects were also recorded. Results : Patients in ketamine group had significantly lower VAS score, longer time to first analgesic (21.6 ± 0.12 Vs 3.8 ± 0.7 hrs), and lower morphine consumption (5.8 ± 1.48 Vs 18.1 ± 1.6 mg) in 24 hours. There were no demonstrable side effects related to ketamine in group K whereas incidence of nausea and vomiting was higher in group C. Conclusion : Our results demonstrate that small dose of ketamine decreases post-operative pain, reduces morphine consumption, and delays patients request for analgesia beyond the clinical duration of action of ketamine after open renal surgery.
  6,033 930 22
Hemodynamic stress response during laparoscopic cholecystectomy: Effect of two different doses of intravenous clonidine premedication
Deepshikha C Tripathi, Komal S Shah, Santosh R Dubey, Shilpa M Doshi, Punit V Raval
October-December 2011, 27(4):475-480
DOI:10.4103/0970-9185.86586  PMID:22096279
Background : Clonidine has emerged as an attractive premedication desirable in laparoscopic surgery wherein significant hemodynamic stress response is seen. The minimum safe and effective dose of intravenous clonidine to attenuate the hemodynamic stress response during laparoscopic surgery has however not yet been determined. Materials and Methods : This prospective, randomized, double-blind controlled study was conducted on 90 adults of ASA physical status I and II, scheduled for laparoscopic cholecystectomy under general anesthesia. Patients were randomized to one of the three groups (n= 30). Group I received 100 ml of normal saline, while groups II and III received 1 μg/ kg and 2 μg/ kg of clonidine respectively, intravenous, in 100 ml of normal saline along. All patients received glycopyrrolate 0.004 mg/kg and tramadol 1.5 mg/kg intravenously, 30 min before induction. Hemodynamic variables (heart rate, systolic, diastolic, mean arterial pressure), SpO2, and sedation score were recorded at specific timings. MAP above 20% from baseline was considered significant and treated with nitroglycerine. Results : In group I, there was a significant increase in hemodynamic variables during intubation pneumoperitoneum and extubation (P<0.001). Clonidine given 1 μg/kg intravenous attenuated hemodynamic stress response to pneumoperitoneum (P<0.05), but not that associated with intubation and extubation. Clonidine 2 μg/kg intravenous prevented hemodynamic stress response to pneumoperitoneum and that associated with intubation and extubation (P<0.05). As against 14 and 2 patients in groups I and II respectively, no patient required nitroglycerine infusion in group III. Conclusions : Clonidine, 2 μg/ kg intravenously, 30 min before induction is safe and effective in preventing the hemodynamic stress response during laparoscopic cholecystectomy.
  4,994 950 13
CASE REPORTS
Electromagnetic interference in a cardiac pacemaker during cauterization with the coagulating, not cutting mode
Basem Abdelmalak, Narasimhan Jagannathan, Faisal D Arain, Susan Cymbor, Robert McLain, John E Tetzlaff
October-December 2011, 27(4):527-530
DOI:10.4103/0970-9185.86600  PMID:22096289
Electromagnetic interference in pacemakers has almost always been reported in association with the cutting mode of monopolar electrocautery and rarely in association with the coagulation mode. We report a case of electrocautery-induced electromagnetic interference with a DDDR pacemaker (dual-chamber paced, dual-chamber sensed, dual response to sensing, and rate modulated) in the coagulating and not cutting mode during a spine procedure. We also discuss the factors affecting intraoperative electromagnetic interference. A 74-year-old man experienced intraoperative electromagnetic interference that resulted in asystole caused by surgical electrocautery in the coagulation mode while the electrodispersive pad was placed at different locations and distances from the operating site (This electromagnetic interference did not occur during the use of the cutting mode). However, because of careful management, the outcome was favorable. Clinicians should be aware that the coagulation mode of electrocautery can cause electromagnetic interference and hemodynamic instability. Heightened vigilance and preparedness can ensure a favorable outcome.
  5,348 498 2
EDITORIALS
Prevention of local anesthetic systemic toxicity
Sandhya Yaddanapudi
October-December 2011, 27(4):438-439
DOI:10.4103/0970-9185.86566  PMID:22096273
  2,849 1,832 5
ORIGINAL ARTICLES
Stellate ganglion block for treatment of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage - A preliminary study
Virendra Jain, Girija P Rath, Hari H Dash, Parmod K Bithal, Rajendra S Chouhan, Ashish Suri
October-December 2011, 27(4):516-521
DOI:10.4103/0970-9185.86598  PMID:22096287
Background : Stellate ganglion block improves cerebral perfusion by decreasing the cerebral vascular tone. Its effects on cerebral vasospasm to relieve neurological deficits have not been evaluated. This prospective observational study was carried out to evaluate the effect of stellate ganglion block on cerebral hemodynamics in patients with symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Materials and Methods : Fifteen patients of either sex, aged 18-75 years, who underwent surgical clipping of aneurysm and developed refractory cerebral vasospasm were included. Stellate ganglion block was performed using 10 ml of bupivacaine 0.5% on the side with maximum cerebral blood flow velocity. Neurological status, cerebral blood flow velocity and pulsatility index were assessed before and 10 minutes, 30 minutes, 2 hours, 6 hours, 12 hours and 24 hours after stellate ganglion block. Results : Improved Glasgow coma score was observed 30 minutes after stellate ganglion block. Neurological deficits reduced in 11 patients. Ipsilateral middle cerebral artery mean flow velocity decreased from 133.66 cm/sec before stellate ganglion block to 110.53 cm/sec at 6 hours (P<0.001) and 121.62 cm/sec at 24 hours (P<0.001) after stellate ganglion block. There was a decrease in ipsilateral anterior cerebral artery mean flow velocity after stellate ganglion block (P<0.001), which persisted for 12 hours. A decline in flow velocities was observed in contralateral middle cerebral artery (P=0.008) and anterior cerebral artery (P=0.041) for 12 hours. Conclusion : This study suggests stellate ganglion block to be an effective modality of treatment for refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage.
  3,800 696 17
CASE REPORTS
Therapeutic drug monitoring of vancomycin in an obese patient with renal insufficiency
Said Abuhasna, Amer H Al Jundi
October-December 2011, 27(4):531-533
DOI:10.4103/0970-9185.86601  PMID:22096290
We report the pharmacokinetics of vancomycin in an obese patient with renal insufficiency using pharmacokinetic equations, and comparing them with actual levels. A 47-year-old man with morbid obesity had a complicated hospital course with acute renal failure. Due to sputum growth of coagulase-negative Staphylococcus aureus, vancomycin 1500 mg intravenously twice daily was given empirically. Peak and trough plasma concentrations were drawn at steady state. Based on levels, true pharmacokinetic parameters for the patient were calculated using equations. This revealed that calculating individual pharmacokinetic parameters using equations may be a valid tool for dosing vancomycin in obese patients with renal insufficiency.
  3,568 739 1
ORIGINAL ARTICLES
Combined spinal epidural and epidural volume extension: Interaction of patient position and hyperbaric bupivacaine
Asha Tyagi, Anil Kumar, Gautam Girotra, Ashok Kumar Sethi
October-December 2011, 27(4):459-464
DOI:10.4103/0970-9185.86577  PMID:22096276
Background : Previous trials have documented failure of block augmentation with epidural volume extension, when applied after the intrathecal injection of hyperbaric bupivacaine was made in sitting position. However, there is no study comparing the effect of change in patient position during block performance, on the results of epidural volume extension. Materials and Methods : The study was conducted in two parts in American Society of Anesthesiologists physical status I or II parturients scheduled for elective cesarean section under regional anesthesia. In the first part, 28 patients were randomized to one of the two groups, depending on whether epidural volume extension was applied following the block in sitting (group SE) or lateral position (group LE) (n=14 each). In the second part of the study another 28 patients were recruited and randomized to receive the block in sitting (group S) or lateral (group L) position (n=14 each), without epidural volume extension. All patients received combined spinal epidural block using needle-through-needle technique with intrathecal injection of 9 mg hyperbaric bupivacaine (0.5%) and 10 μg fentanyl. Epidural volume extension was performed using 5 ml normal saline in groups SE and LE. Results : In the first part of the study, the maximum sensory block level was higher in group LE vs. SE (P<0.05). In the second part of the study, no significant difference was seen in the maximum sensory level between group S and group L (P>0.05). Conclusions : If epidural volume extension is being applied with intention of rapid extension of sensory block when hyperbaric bupivacaine has been injected intrathecally, the combined spinal epidural block should be performed in lateral position rather than in the sitting position.
  3,138 922 1
CASE REPORTS
Anesthetic management of a patient with sickle cell disease for common bile duct exploration
Sarika Subhash Ingle, Pravin Ubale
October-December 2011, 27(4):547-549
DOI:10.4103/0970-9185.86606  PMID:22096295
Patients with sickle cell disease (SCD) may present to the anesthetist in different clinical settings like perioperative care, management of acute painful crisis and intensive therapy for acute respiratory failure. We describe the successful management of a 34-year-old female patient with SCD, posted for cholecystectomy with common bile duct exploration under general and epidural anesthesia. The importance of preoperative stabilization and careful anesthetic strategy is emphasized.
  3,552 447 4
Arrhythmias following spinal anesthesia for cesarean delivery - Is Wenckebach common?
Seema Kalra, Nitin Hayaran
October-December 2011, 27(4):541-543
DOI:10.4103/0970-9185.86604  PMID:22096293
Arrhythmias in pregnancy are common and may cause concern for the well-being of both mother and fetus. Generally, no previous history of heart disease is elicited and majority of the arrhythmias are benign. Bradycardia is commonly seen following subarachnoid block for cesarean section. However, the incidence of subsequent heart block is low. This case report highlights the occurrence of perioperative arrhythmias following sympathetic blockade in pregnant patients and their early detection by vigilant monitoring.
  3,468 397 1
ORIGINAL ARTICLES
Effect of one minimum alveolar concentration sevoflurane with and without fentanyl on hemodynamic response to laryngoscopy and tracheal intubation
Anwar Hoda, Fauzia A Khan
October-December 2011, 27(4):522-526
DOI:10.4103/0970-9185.86599  PMID:22096288
Background : Drug combinations can be used for optimum obtundation of the hemodynamic response to tracheal intubation. The objective of this trial was to compare the hemodynamic response to laryngoscopy and tracheal intubation after administration of 2 μg/kg fentanyl bolus or a placebo with 2% end tidal sevoflurane at induction of anesthesia. Materials and Methods : A total of 70 surgical patients of either gender, age 18-45 years were selected for this double blind, randomized, placebo controlled trial, with 35 in each group. All patients received a standardized induction with thiopentone, atracurium, and an end tidal concentration of 1 minimum alveolar concentration (MAC) sevoflurane. Heart rate and noninvasive blood pressure were compared to the baseline post induction and for seven minutes post intubation. Some adverse events were noted. Results : The maximum heart rate response was significantly less in the sevoflurane fentanyl group (15% vs. 22%). Significant difference between groups was observed in the systolic blood pressure at six minutes post intubation. Hemodynamic adverse events recorded were similar. Conclusion : Addition of 2 μg fentanyl bolus to 1 MAC sevoflurane anesthesia at induction attenuated the hemodynamic response to a maximum of 15% above baseline values.
  3,091 565 3
Bier's block using lignocaine and butorphanol
Abhishek Bansal, Shikha Gupta, Dinesh Sood, Suneet Kathuria, Anurag Tewari
October-December 2011, 27(4):465-469
DOI:10.4103/0970-9185.86580  PMID:22096277
Background : Opioids are most commonly used as adjuncts in intravenous regional anesthesia (IVRA) to improve the quality of intraoperative and postoperative analgesia. There is paucity of literature on the use of butorphanol in IVRA. Aims : The aim of this study was to evaluate the likely benefits of addition of butorphanol to lignocaine in Bier's block in terms of onset and duration of sensory block and also for analgesic requirement in postoperative period. Settings and Design : A randomized double blind study was conducted at Tertiary Care Educational Institute. Patients and Methods : A total of 40 adult ASA I or II patients scheduled to undergo upper limb surgery were randomized in two groups (n=20). Group I received 3 mg/kg of lignocaine alone and group II received 1 mg butorphanol in addition to 3 mg/kg lignocaine. Sensory block onset time and time to recovery from sensory block after tourniquet deflation were noted using the pin prick method. Duration of postoperative analgesia was noted using a visual analogue scale. All the patients were compared for the time to first rescue analgesic consumption and total analgesic consumption in first 24 hours postoperatively. Statistical Analysis Used : The statistical analysis was done using unpaired Student's t-test. Results : Our study showed significant prolongation of postoperative analgesia in group II as noted by the time to first analgesic requirement. Total analgesic consumption in first 24 hours postoperatively was less in group II. Sensory block onset time and time to recovery from sensory block after tourniquet deflation, did not show any significant difference between the two groups. Conclusions : Addition of butorphanol to lignocaine in IVRA significantly prolongs the duration of postoperative analgesia and 24 hours analgesic consumption is less in patients receiving butorphanol along with lignocaine in IVRA. However, there is no effect on sensory block onset time and time to recovery from sensory block.
  2,910 584 2
The analgesic efficacy of peritubal infiltration of 0.25% bupivacaine in percutaneous nephrolithotomy - A prospective randomized study
Geeta P Parikh, Veena R Shah, Manisha P Modi, Nikhil C Chauhan
October-December 2011, 27(4):481-484
DOI:10.4103/0970-9185.86591  PMID:22096280
Background : Percutaneous nephrolithotomy is a routine endourologic procedure in patients with renal stones. Although it is less painful than open surgery, good postoperative analgesia is required to alleviate pain around nephrostomy tube. Materials and Methods : Sixty ASA grade I patients, 18 to 60 years of age, of either sex were randomized to receive 20 ml of 0.25% bupivacaine (group S) or 20 ml of normal saline (group C) through 23-gauge spinal needle along the nephrostomy tube under fluroscopic guidance at the end of the surgery. Postoperative pain score was assessed by visual and dynamic visual analog scores. When the scores were ≥4, rescue analgesia was given in the form of tramadol 1 mg/kg i.v. upto maximum 400 mg in 24 hours. Time to first demand analgesia and total dose of tramadol in first 24 hours was noted. Results : Pain scores at rest and during coughing as well as rescue analgesic requirements for first 24 hours were significantly less in the bupivacaine group than those of the control group (P < 0.05). The first request for demand analgesia was around 9 hours in group S, while in group C it was around 2.6 hours (P < 0.05). Total requirement of tramadol in group S was 119.3 mg and in C group it was 276.8 mg (P < 0.05). Conclusion : Peritubal infiltration of 0.25% bupivacaine is efficient in alleviating postoperative pain after PCNL.
  3,003 446 12
LETTERS TO THE EDITOR
Endotracheal tube fixation in neurosurgical procedures operated in prone position
Georgene Singh, Sethuraman Manikandan, Praveen Kumar Neema
October-December 2011, 27(4):574-575
DOI:10.4103/0970-9185.86621  PMID:22096310
  3,030 393 1
ORIGINAL ARTICLES
Effect of intraoperative depth of anesthesia on postoperative pain and analgesic requirement: A randomized prospective observer blinded study
Neeru Sahni, Lakesh K Anand, KK Gombar, Satinder Gombar
October-December 2011, 27(4):500-505
DOI:10.4103/0970-9185.86595  PMID:22096284
Background : Intraoperative depth of anesthesia may affect postoperative pain relief. This prospective, randomized, and observer-blinded study assessed the effect of intraoperative depth of anesthesia on the postoperative pain and analgesic requirements in patients undergoing laparoscopic cholecystectomy. Materials and Methods : A total of 80 patients were randomly divided into two groups of 40 each. A standard technique for anesthesia was followed in all patients. Depth of anesthesia was monitored by bispectral index (BIS) and adjusted with 0.5 to 1.5% isoflurane in group S by addition of propofol in group B, if required, to maintain a BIS value of 45 to 40. Postoperative analgesia was provided by tramadol 1 mg/kg every 6 hours and rescue analgesia by morphine boluses. Postoperative pain was assessed by Visual analogue scale score at 0, 8, 16, and 24 hours. Results : The demographic characteristics were comparable in both groups. The mean BIS value in Group S was 63.32 ± 11.43 and 45.06 ± 15.31 in Group B, well in the range of 40 to 60, reflecting adequate hypnotic effect for general anesthesia. The mean arterial pressure was low in group B throughout the surgery (P<0.05-0.001). The pain score were lower in group B at 0 and 8 hours postoperatively when compared with group S (P<0.05). The rescue analgesic requirement was less in group B, compared with group S (P<0.05). Conclusion : Maintaining BIS to a value of 45 to 40 throughout the surgery results in better postoperative pain relief and decreased requirement of rescue analgesic without any untoward effect.
  2,820 574 7
LETTERS TO THE EDITOR
Intraventricular hemorrhage after ventriculoperitoneal shunt removal
Surya Kumar Dube, Tumul Chowdhury, Rahul Yadav, Girija Prasad Rath
October-December 2011, 27(4):570-571
DOI:10.4103/0970-9185.86617  PMID:22096306
  3,013 295 1
ORIGINAL ARTICLES
Pre-emptive oral dexmethorphan reduces fentanyl-induced cough as well as immediate postoperative adrenocortico-tropic hormone and growth hormone level
Avik Mukherjee, Asim Kumar Kundu, Sudipta Ghosh, Rajat Choudhuri, Bijoy Kumar Bandopadhyay, Sugata Dasgupta
October-December 2011, 27(4):489-494
DOI:10.4103/0970-9185.86593  PMID:22096282
Background : Fentanyl-induced cough is not always benign and brief and can be remarkably troublesome, spasmodic, and explosive. Dextromethorphan, an opioid derivative with an antitussive action, may be effective in reducing the fentanyl-induced cough. Dextromethorphan, a N-methyl D aspartate receptor antagonist, may have some effect on diminishing the stress response to surgery. This study was undertaken to determine whether preoperative dextromethorphan could effectively attenuate its incidence, severity, and effect on postoperative stress hormone levels. Materials and Methods : Three hundred and twenty patients of American society of anesthesiologists I-II, aged 18-60 years, undergoing elective laparoscopic cholecystectomy or appendicectomy were randomly allocated into two groups (Group C, control; Group D, dextromethorphan) consisting of 160 patients each. Patients in Group D received dextromethorphan 40 mg orally and in Group C received placebo tablets 60 minutes before induction of anesthesia. The incidence of cough was recorded for 1 minute after fentanyl injection and graded as none (0), mild (1-2), moderate (3-5), and severe (>5 cough). Blood samples were collected for estimation of stress hormone levels before surgery and again at 1 hour and 24 hours postoperatively and compared. The appearance of adverse reactions was recorded. Results : The incidence of reflex fentanyl cough was lower in dextromethorphan group (3.9%) in comparison to placebo (59.8%). Five patients developed mild and one moderate cough in the dextromethorphan group. In the control group, 31 patients developed mild, 29 moderate, and 32 severe cough. The stress hormones were significantly higher at 1 hour and 24 hours postoperatively in both groups in comparison to its preoperative values. However, at 1 hour postoperatively, adrenocorticotropic hormone, epinephrine, and growth hormone values were significantly low in the dextromethorphan group (61.5 ± 21.1 pg/ ml, 142.1 ± 11.2 pg/ml, and 3.8 ± 0.7 ng/ml) relative to the control group (73.4 ± 21.9 pg/ml, 158.9 ± 17.9 pg/ml, and 4.2 ± 1.3 ng/ml), but changes became insignificant at 24 hours postoperatively. Conclusion : Preoperative oral dextromethorphan 40 mg decreased the incidence and severity of fentanyl induced cough and reduced the rise in stress hormones at 1 hour postoperatively.
  2,706 435 5
CASE REPORTS
Antiplatelet therapy in patients with coronary artery stents for noncardiac surgery: Role of thromboelastography
Rashmi Jain, Jayashree Sood
October-December 2011, 27(4):537-540
DOI:10.4103/0970-9185.86603  PMID:22096292
The perioperative course of the patients who have undergone coronary stent placement was studied. These patients were on dual antiplatelet therapy and were posted for noncardiac surgery. Clopidogrel had been discontinued for a variable duration before noncardiac surgery. Thromboelastography (TEG) was performed preoperatively to assess their fitness for surgery. The surgery and the postoperative period were uneventful in all the patients. There was no incidence of increased bleeding in any of the patients. Blood transfusion was not required in any patient. We concluded that standard TEG can be used when in dilemma about the fitness of the patient for surgery. Although there are clear guidelines about the patients who are on dual antiplatelet therapy, in clinical practice, it is important to weigh the risk-benefit to the advantage of the patient. If we stop the dual antiplatelet therapy in a patient with drug eluting stent within 1 year of implantation, the risk of major adverse cardiac event increases many fold. If we continue clopidogrel and aspirin during surgery, the risk of bleeding increases but is not life-threatening, except when surgery is performed in closed spaces. Thus, to continue dual antiplatelet medication intraoperatively is better than to stop it. If the medicine has to be withheld, it should be withheld for the minimal possible duration and a TEG should be performed.
  2,534 570 2
Unilateral pulmonary edema after laparoscopic nephrectomy
Shreepathi Krishna Achar, Cherish Paul, Elsa Varghese
October-December 2011, 27(4):556-558
DOI:10.4103/0970-9185.86609  PMID:22096298
Unilateral-dependent pulmonary edema though reported in laparoscopic donor nephrectomies, has not been reported after laparoscopic non-donor nephrectomies. A 75-kg, 61-year-old man, a diagnosed case of right renal cell carcinoma was scheduled for laparoscopic nephrectomy. After establishing general anesthesia, the patient was positioned in the left-sided modified kidney (flank) position. During the 5.75-hour procedure, he was hemodynamically stable except for a transient drop in blood pressure immediately after positioning. Intra-abdominal pressure was maintained less than 15 mmHg throughout the procedure. Blood loss was approximately 50 mL and urine output was 100 mL in the first hour followed by a total of 20 mL in the next 4.75 hours. Total fluid received during the procedure included 1.5 L of Ringer's lactate and 1.0 L of 6% hydroxyethyl starch. After an uneventful procedure he developed respiratory distress in the postoperative period with a radiological evidence of dependent lung edema. Clinical and radiological improvement followed noninvasive ventilation, intravenous diuretics and oxygen therapy.
  2,640 358 1
Use of intubating laryngeal mask airway in a morbidly obese patient with chest trauma in an emergency setting
Tripat Bindra, Sanjay K Nihalani, Poonam Bhadoria, Sonia Wadhawan
October-December 2011, 27(4):544-546
DOI:10.4103/0970-9185.86605  PMID:22096294
A morbidly obese male who sustained blunt trauma chest with bilateral pneumothorax was referred to the intensive care unit for management of his condition. Problems encountered in managing the patient were gradually increasing hypoxemia (chest trauma with multiple rib fractures with lung contusions) and difficult mask ventilation and intubation (morbid obesity, heavy jaw, short and thick neck). We performed awake endotracheal intubation using an intubating laryngeal mask airway (ILMA) size 4 and provided mechanical ventilation to the patient. This report suggests that ILMA can be very useful in the management of difficult airway outside the operating room and can help in preventing adverse events in an emergency setting.
  2,554 439 4
ORIGINAL ARTICLES
Patient's experiences and satisfaction with preanesthesia services: A prospective audit
Anju Gupta, Nishkarsh Gupta
October-December 2011, 27(4):511-515
DOI:10.4103/0970-9185.86597  PMID:22096286
Background : Patient satisfaction with the medical services is an important indicator of quality of healthcare but is seldom given importance in our country. It is difficult to measure patient satisfaction, especially in pre- and perioperative period. Materials and Methods : We conducted this audit by means of a questionnaire designed to assess preanesthetic clinic services in a large government hospital. A total of 200 patients were randomly selected to respond to a multiple item questionnaire. Statistical Analysis : A database was created and analyzed using Microsoft Excel. Results : 95% patients filled the proforma. Most of the patients (60%) were not aware of the purpose of visit to preanesthetic clinic. Majority of them were attended in time by the doctors but most of them (60%) received fitness after 2 to 3 visits. Majority was not explained about the preanesthesia instructions. Most of them were not satisfied by amenities in hospital. Several studies have shown that a thorough preoperative examination can be as effective as an anxiolytic premedication and can increase quality of care. In our study, location of preanesthetic clinic and unable to get fitness in first visit (because of lack of coordination between doctors of various specialties) were the major hindrances. Conclusion : Measures should be taken to improve the functioning of preanesthesia clinic and patient satisfaction.
  2,362 497 4
Role of hydrocortisone in prevention of pain on propofol injection
Monu Yadav, Padmaja Durga, R Gopinath
October-December 2011, 27(4):470-474
DOI:10.4103/0970-9185.86582  PMID:22096278
Background and Objectives : Pain following intravenous injection of propofol continues to be an intriguing problem. None of the commonly used methods completely attenuate the pain. Inflammatory response to propofol contributes to the pain. Role of hydrocortisone in attenuating pain has not been evaluated. This study was conducted to compare the efficacy of lignocaine and hydrocortisone in attenuation of pain following intravenous injection of propofol. Materials and Methods : A prospective randomized double-blind, placebo-controlled study was conducted on 72 adult patients belonging to American Society of Anesthesiologists (ASA) physical status I or II, scheduled to undergo elective surgery. They were randomly assigned to four groups of 18 each. Group NS, group LG, group HC10, and group HC25. The groups received 2 ml normal saline, 2 ml 2% lignocaine, 10 mg/2 ml hydrocortisone, and 25 mg/2 ml hydrocortisone, respectively, as pretreatment. Propofol was injected 30 sec later. A blinded researcher assessed the patient's pain level using a four point verbal rating scale. Results : The four groups were comparable in respect to patient's characteristics. There was no significant difference of hemodynamics changes during propofol induction between all the groups. There was no statistically significant difference in the incidence of pain between patients who received hydrocortisone and the placebo group. The incidence of pain was significantly less in group LG than other three groups. Conclusion : Use of intravenous low dose hydrocortisone pretreatment of the vein does not attenuate pain following propofol injection.
  2,266 547 -
Student assessment of teaching effectiveness of "bundle of changes"-A paired, controlled trial
Seema Kalra, Y Nelson, Pratima Dave, Rachna Wadhwa
October-December 2011, 27(4):506-510
DOI:10.4103/0970-9185.86596  PMID:22096285
Background : Inching toward optimum patient safety by training personnel is the prime aim of the ongoing medical education. Aims : To assess whether lectures targeted to improve quality care in ICU could improve ICU practitioners' knowledge levels and to evaluate the effectiveness of teaching. Settings and Design : In this paired controlled trial, 50 ICU practitioners, i.e., anesthesia and medicine residents and nursing staff of our hospital attended a series of four lectures. Materials and Methods : Participants enrolled in the study attended lectures on "bundles of changes" in ICU, namely, introduction, ventilator bundle, central line bundle, and catheter-related blood stream infections and severe sepsis bundle. They were given a questionnaire of 15 multiple choice questions prior to and after the lectures. We evaluated their immediate knowledge acquisition and retention recall. Subsequently, they evaluated the effectiveness of the teaching programme by a questionnaire of 10 multiple choice questions. Statistical analysis used: Data for statistical analysis were tabulated and analyzed using SPSS-Pc 11.5 version software. Results : Fifty study participants completed all three questionnaires. There was an increase in the overall mean score in the post-lecture test (4.58 + 1.51 SD) (P < 0.001). Overall mean score increased significantly from 8.30 + 1.34 SD in THE pre-lecture test - to 12.02 + 1.61 SD in the postlecture re-test (3.72 + 1.39 SD) (P < 0.001). In the evaluation of teaching effectiveness 88% respondents agreed to most of the questions, signifying the effectiveness of the lectures. However, there were 10% who disagreed to the questions and only 2% strongly disagreed to all the questions. Conclusions : Teaching programmes such as the "bundle of changes" are effective in improving immediate knowledge acquisition and retention recall of the participants if designed keeping the target audience in mind.
  2,337 361 2
CASE REPORTS
Successful anesthetic management of a child with blepharophimosis syndrome and atrial septal defect for reconstructive ocular surgery
Dalim Kumar Baidya, Puneet Khanna, Anil Kumar, Dilip Shende
October-December 2011, 27(4):550-552
DOI:10.4103/0970-9185.86607  PMID:22096296
Blepharophimosis syndrome is an autosomal dominant disorder characterized by eyelid malformation, involvement of reproductive system and abnormal facial morphology leading to difficult airway. We report a rare association of blepharophimosis syndrome and atrial septal defect in a 10-year-old girl who came for reconstruction surgery of eyelid. The child had dyspnea on exertion. Atrial septal defect was identified preoperatively by clinical examination and echocardiography. Anesthesia management was complicated by failure in laryngeal mask airway placement and Cobra perilaryngeal airway was subsequently used.
  2,329 304 2
LETTERS TO THE EDITOR
Anesthetic management for removal of adrenocortical carcinoma with thrombus in the inferior vena cava extending to the right atrium
Kamal Kumar, Sujatha Basker, L Jeslin, Chitra Srinivasan, Edwin Zedek
October-December 2011, 27(4):571-573
DOI:10.4103/0970-9185.86618  PMID:22096307
  2,240 385 3
Low dose spinal anesthesia for peripartum cardiomyopathy
Kapil Gupta, Surender Pal Gupta, Shanil Jose, Hemavathi Balachander
October-December 2011, 27(4):567-568
DOI:10.4103/0970-9185.86615  PMID:22096304
  2,018 452 1
CASE REPORTS
Tumor lysis syndrome developing intraoperatively
Ankur Verma, Ruchi Mathur, Munish Chauhan, Prashant Ranjan
October-December 2011, 27(4):561-563
DOI:10.4103/0970-9185.86611  PMID:22096300
Tumor lysis syndrome is a potentially life threatening condition which is most commonly encountered in patients being treated with chemotherapy. We report a case of spontaneous tumor lysis syndrome that developed intraoperatively in a patient with undiagnosed Burkitt's lymphoma. Characteristic electrolyte disturbances and white emulsion like urine following laparotomy and tumor handling intraoperatively suggested the diagnosis. This is a rare perioperative complication and the report emphasizes the importance of being vigilant in recognizing the same.
  2,094 346 3
Remifentanil apnea: Case report and review of the literature
Nissar Shaikh, Yolande Hanssens, André Louon
October-December 2011, 27(4):553-555
DOI:10.4103/0970-9185.86608  PMID:22096297
Remifentanil is an opioid analgesic frequently used in intensive care patients because of its rapid onset of action, potency, and ultra-short duration. If an excessive dose is given, it leads to rapid, short lasting, potentially life-threatening side effects such as apnea, bradycadia, hypotension, and rigidity, following rapid peak serum levels. We report a 36-year-old woman developing apnea with bradycardia and hypotension, following an infusion in the central venous catheter lumen that had been used for remifentanil till tracheal extubation. The patient was immediately ventilated with bag-valve-mask and improved within 8 minutes. She became fully awake, heart rate and blood pressure returned to normal, and oxygen saturation improved to 100%. Acute care physicians, intensivists, anesthesiologists, and critical care nurses should be aware of this clinical problem in order prevent it as much as possible and to initiate immediate resuscitative measures.
  2,039 397 2
Foreign body removal with repair of iatrogenic tracheo-bronchial tear repair: An anesthetic challenge
Vikram Uday Lahori, Shipra Aggarwal, Pemala Simick, Sudhindra Dharmavaram
October-December 2011, 27(4):534-536
DOI:10.4103/0970-9185.86602  PMID:22096291
Foreign body aspiration into the airway is common in the pediatric age group and its anesthetic management is a challenge. Iatrogenic tracheo-bronchial injury further worsens the situation. Flexible pediatric fiberscope is the gold standard for securing the airway in cases of airway injury. We present a case of a 7-year-old girl who presented to the hospital with signs and symptoms of foreign body aspiration and suspected tracheo-bronchial tree injury. The impacted foreign body was removed by rigid bronchoscopy and the presence of a tracheo-bronchial tear was confirmed. To repair the airway tear, thoracotomy was planned necessitating one lung ventilation. A pediatric flexible fiberscope was not available, so left endobronchial intubation for one lung ventilation was done with the help of an airway exchange catheter using a rigid bronchoscope as a conduit. Subsequent intra-operative and post-operative period were uneventful.
  2,055 335 2
LETTERS TO THE EDITOR
Malfunctioning catheter connector: An unusual and rare cause of epidural catheter blockade
Devalina Goswami, Aruna Jain, Homay Vajifdar
October-December 2011, 27(4):566-567
DOI:10.4103/0970-9185.86614  PMID:22096303
  2,036 256 -
CASE REPORTS
Transient brachial monoparesis following epidural anesthesia for cesarean section
Tejesh C Anandaswamy, Manjunath A Chikkapillappa, Geetha C Rajappa, Shivakumar Shivanna
October-December 2011, 27(4):559-560
DOI:10.4103/0970-9185.86610  PMID:22096299
Monoparesis following lumbar epidural block is a rare occurrence, with few cases reported in the literature. We report development of transient brachial monoparesis following epidural anesthesia in a parturient for cesarean section. The patient received a mixture of 15 mL of 2% lignocaine with 50 mcg fentanyl epidurally to achieve a blockade up to T6 level. She remained hemodynamically stable throughout the procedure, with no respiratory distress or desaturation. However, near the end of surgery, she developed weakness in the right upper limb. The weakness lasted for 90 min, followed by complete neurological recovery. Subsequent hospital stay was uneventful.
  1,740 315 -
LETTERS TO THE EDITOR
Supraventricular tachycardia after an intercostal nerve block with bupivacaine treated with 10% intralipid
Rakhee Goyal, RN Shukla, Gaurav Kumar, M Tandon
October-December 2011, 27(4):564-565
DOI:10.4103/0970-9185.86612  PMID:22096301
  1,670 360 2
Ventilator malfunction
BR Krishna Kumar, M Ravi, K Dinesh, A Nanda
October-December 2011, 27(4):576-576
DOI:10.4103/0970-9185.86623  PMID:22096312
  1,656 284 1
Intubating children with giant occipital encephalocele in lateral position: Right or left side?
Charu Mahajan, Girija Prasad Rath
October-December 2011, 27(4):575-575
DOI:10.4103/0970-9185.86622  PMID:22096311
  1,656 263 2
Difficult intubation in traumatic tongue bifurcation
Vinit K Srivastava, Sanjay Agrawal, Sunil K Kedia, Anuj Mohan
October-December 2011, 27(4):565-566
DOI:10.4103/0970-9185.86613  PMID:22096302
  1,590 277 -
Comparison of propofol-based anesthesia to conventional inhalational general anesthesia for spine surgery-Few queries
Anila D Malde
October-December 2011, 27(4):573-573
DOI:10.4103/0970-9185.86619  PMID:22096308
  1,261 252 1
Authors' reply
LD Mishra, SK Pradhan, CS Pradhan
October-December 2011, 27(4):573-574
DOI:10.4103/0970-9185.86620  PMID:22096309
  1,130 205 2
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