Indian Journal of Clinical Anaesthesia

6-14

Authors: Badri Prasad Das, Ram Badan Singh, Rajiv Kumar Dubey, Yashpal Singh

Background: Anaesthesia and surgery (thoracic and upper abdominal) are very stressful and painful and pain if not relived adequately it may lead to hemodynamic instability with respiratory compromise and increased complications in intra-operative and Post-operative period. The common agents available for sedation and analgesia includes opiates and benzodiazepines. Use of these agents have side effects, including respiratory and cardiovascular depression. Dexmedetomidine HCl, a highly potent α2-adrenergic agonist, have sedative, analgesic, hypnotic and anxiolytic effects without causing respiratory depression. Objective: The objective of this study is to find out safe and effective adjuvant of analgesic and sedative drug which can reduce stress of anesthesia and surgery and provide stable hemodynamics in intra operative period with rapid recovery from anesthesia. Material and Methods: After ethical clearance and informed consent 120 eligible paediatric patients aged 2-10 years, of either sex, ASA physical status I and II scheduled for thoracic and upper abdominal surgeries were allocated randomly into 2 groups (DEX group and NS group) each containing 60 patients. DEX group received Dexmedetomidine 1mcg/kg (loading) (made to 20ml) slow IV injection over 20minutes, before inducing anaesthesia, followed by 0.5mcg/kg/hour (maintenance) peri & post-operatively over 6hours through infusion pump. NS Group received only normal saline 20ml slow IV injection over 20minutes, before inducing anaesthesia and continued infusion in same way as DEX group. General anaesthesia was induced using a standard dosage protocol. Hemodynamic parameters monitored and recorded at frequent interval. Statistical analysis was done and data were analysed. Results: Stress induced Hemodynamic response during laryngoscopy, intubation, surgery and extubation was significantly less in Dex group patients with lesser halothane consumption and rescue analgesic requirement ( p<0.05) in intra operative period. Conclusion: Use of IV Dexmedetomidine peri-operatively, significantly decreases haemodynamic response of stress related to anaesthesia and surgery. It also decreases sedative and analgesic requirements with good pain relief and stable haemodynamics with lower post- operative complications.

19-26

Authors: Shikha Sharma, Nandita Mehta, D.S.Charak

Background: It is an established fact that endotracheal intubation allows the best control of airway and ventilation. Any difficulty in intubation which has not been anticipated and evaluated can lead to adverse outcomes such as hypoxia, aspiration of vomitus etc. The preoperative assessment for recognition of difficult airway in advance is the best method of avoiding any disaster caused by the inability to maintain the airway. Objectives: The main objective of this study was to assess the airway by various tests and then grade the view obtained at laryngoscopy, in all patients undergoing elective surgery requiring general anaesthesia and endotracheal intubation. Then to compare and correlate the laryngoscopic view obtained with the findings of airway assessment tests. Material and Methods: A total 150 adult patients of either sex of ASA class I and II , undergoing elective surgery for various procedures requiring general anaesthesia with endotracheal intubation were included in our study. Assessment of the airway was made by viewing the patient from lateral and anterolateral positions; viewing and palpating the neck anteriorly and laterally; extending and flexing the head and neck maximally; examining the mouth opening, teeth & oral cavity; and determining patency of nostrils. The following measurements were undertaken and recorded: a) Modified Mallampati Test, b) Thyromental Distance, c) Upper lip Bite Test, d) Head Extension, e) Wilson’s criteria. After induction of anaesthesia, laryngoscopy was performed in classical intubating position with McIntosh blade and the laryngoscopic grade was recorded as described by Cormack and Lehane. Statistical analysis was done for the usefulness of various tests (alone or in combination) for identifying difficult intubation. Conclusion: No method either individual or in combination with other, identifies all cases of difficult intubation. Wilson score and neck extension were most accurate individual methods. Combination of 3 tests is not required when 2 tests combined together can give better results.

32-35

Authors: Pushkar Desai, Shirish Mahure, Manjula Sarkar, Sanjeeta Umbarkar

Background: Central venous and pulmonary artery catheter are integral part of hemodynamic monitoring during off pump coronary artery bypass grafting surgery. Methods: In this prospective randomized trial, sixty patients were divided equally into two groups, to receive either central venous or pulmonary artery catheter after induction of anesthesia with high dose of opioid and Inj pancuronium. Patients between 35-65 years with ejection fraction 40-60% undergoing elective off pump coronary artery bypass surgery were included while those with left ventricular dysfunction were excluded. All patients were operated by same team of surgeons. Systolic blood pressure (SBP) and/or mean arterial pressure (MAP) was kept above 90 and 60 mm Hg respectively throughout perioperative period by fluid volume expansion and inotropic support. Nitroglycerine was used for blood pressure control and coronary vasodilation. Both groups were compared with respect to intervention requiring inotropes and its duration, ICU stay and any complications occurred. Results: Significant number of patients in CVP group were started on inotropes than PAC group (66.6% vs 40%, P=0.038). Among these, 75% in Gr.A needed it for less than 24 hours compared to 65% in Gr. B. Both groups needed similar trials of fluid challenge [40% vs 53.33%; P=0.30] and showed similar duration of intensive care unit stay (more than 48 hrs) [66.67% vs 53.3%; p=0.29, chi square test]. More number of patients developed complications in CVP group [6.6 vs 16.6%; P=0.22]. One patient in each group had mortality. Conclusion: PA catheter guided management does not provide additional benefit over CVP guided management alone during OPCAB surgery in patients with preserved LV function.

41-47

Authors: Abhishek Chatterjee, D.P.Samaddar, Srividhya, Deb Sanjay Nag, Nishant Sahay

Background: Laryngoscopy and tracheal intubation induce potentially harmful hemodynamic response. None of the advocated methods had been accepted as the most effective option. Ease of use and economical advantages of the suggested methods are also important considerations. This study was designed to address this concern by using two common drugs (intravenous lignocaine vs.oral clonidine). Material and Method: A randomized, controlled, prospective, single blind study was planned involving 70 patients divided equally into two groups – Group C (patients received oral Clonidine 4 mcg/kg 90 minutes prior to intubation) and Group L (Patients received intravenous Lignocaine 2 mg/kg 3 minutes prior to intubation). Observations: Focus was on hemodynamic parameters - Heart rate, Systolic, Diastolic, Mean blood pressures and Rate pressure product, however, sedation and anxiety score was also compared. Results: Demographic profile and time taken for intubation was same in both the groups. Post intubation rise (>25 % from base line) in heart rate was observed more in Gr.L (54.28 %) as compared to 5.71 % in Gr.C. Systolic, diastolic and mean arterial blood pressure variations were observed more in Gr L (42.85 %, 25.71 % and 22.85%) as compared to Gr. C (2.85 %, 5.71 % and 2.85 % ). Difference for all the above parameters was statistical significant (p-value < 0.05). However 40 % of patients were drowsy, 82.85 % of patients had dryness of mouth, two patients (5.71 %) had bradycardia and hypotension in Clonidine group, whereas such observations were not made in Lignocaine group. Conclusion: Oral Clonidine at a dose of 4 mcg/kg body weight (up to a maximum limit of 200 mcg) therefore can be considered as better option than time tested intravenous Lignocaine

57-62

Authors: Ghanta .V. Nalini Kumari, Sushma Ladi

Introduction: Majority of laparoscopic surgeries are associated with highest incidence of post-operative nausea and vomiting (PONV). It is one of the important concerns to choose appropriate anaesthesia drug in the laparoscopic surgeries. The aim of the present study is to perform comparison of induction sevoflurane and propofol and its effects on incidence of PONV in the first 24 hr after laparoscopic day surgery. Materials and Methods: The present study has considered 60 patients in age group of 18-60 of ASA grade 1 and 2 scheduled for general surgeries. The present study has used a randomized and single blinded study. The patients have divided into two groups; those are propofol group (P group) and sevoflurane group (S Group) of 30 patients each. After completion of surgery, the patient was under observation first 24 hours in recovery room. Observations and Results: The present study revealed that around 63.33 % of patients have categorized in grade 1 in group S patients. Similarly, in group P, around 90 % of patients have categorized in grade 1. The study also revealed that around 36.67% of patients have suffered with PONV ( grade 2 (3 patients) and grade 3 (8 Patients)) in group S and only 10% (grade 2 (2 patients) and grade 3 (1 patient)) of the patients have suffered with PONV in group P. The study observed that there was significant numerical difference in grade 2 and grade 3 in two groups under the study. The statistical test revealed that there was no difference between two groups. Conclusions: The study observed that there was a significant numerical difference in grade 2 and grade 3 in two groups under the study. The statistical test revealed that there was no difference between in two groups.

70-73

Authors: Mamta Khandelwal, Debojyoti Dutta, Samiksha Khanooja, Sunil Chauhan, Mohit Anand

Crigler Najjar syndrome (CNS) is a rare disorder which affects the metabolism of bilirubin and clinically manifests as intense unconjugated hyperbilirubinemia without evidence of hemolysis. CNS-II in pregnant woman is a very rare condition and till now very little have been known about the maternal and foetal effect in this condition .We are presenting the anaesthetic management of a diagnosed case of Crigler –Najjar syndrome (CNS) 2 posted for emergency lower segment caesarean section (LSCS).