Indian Journal of Clinical Anaesthesia

139-143

Authors: Debaprasad Mohanty, Mahendra Kumar Nayak, Khageswar Raut, Sidharth Sraban Routray, Debasis Mishra.

Ventilator Associated Pneumonia (VAP) refers to a type of pneumonia that occurs more than 48–72 hours after endotracheal intubation. Risk factors include prolonged mechanical ventilation, reintubation after extubation. Our aim was to find the incidence of VAP, total days of mechanical ventilation, days of ICU and hospital stay at our institution, proportion of various bacterial pathogens isolated from tracheal aspirate of patients with VAP and their antibiotic sensitivity pattern. Material &Methods: A prospective cohort study was conducted on 100 patients who were admitted to medical intensive care unit of SCB Medical college and on ventilatory support for two or more days and were not suffering from pneumonia prior to putting them on ventilator. Endotracheal aspirates were obtained under strict aseptic precautions using a 22-inch Romson’s 12F suction catheter with a mucus extractor. Gram staining and biochemical tests for identification and antimicrobial susceptibility test were performed. The patients were classified into four groups named VAP, NON VAP, SURVIVORS and NON SURVIVORS. All the data collected were compiled and tabulated. Observation: The incidence of VAP in this study was 30%. The association between genders (p value-0.372), age (p value-0.929) and VAP infection was not found to be significant. There was no significant correlation between the primary disease and development of VAP (p value =0.24). Most common organism isolated was P. aeruginosa, (9 isolates) followed by MRSA (7 isolates) and most of them were resistant to commonly used antibiotics. Conclusion: VAP patients have higher mortality rate, longer duration of mechanical ventilation and duration of hospital stay than NON VAP patients. Early diagnosis of VAP and initiation of appropriate antibiotic treatment is vital to prevent the adverse outcomes.

148-154

Authors: V. Bhavani, I Joseph Raajesh.

Patients presenting with uterovaginal prolapse for vaginal hysterectomies will usually be in the age group of above 50years. Effective and prolonged post-operative analgesia will be of paramount importance in this group of patients as it is not uncommon to find associated comorbidities such as hypertension, diabetic mellitus and ischaemic heart diseases in these population. Pain free postoperative period is mandatory in all post-surgical patients. Effective postoperative analgesia not only improves the patient comfort it also reduces the risk of deep vein thrombosis by early ambulation. Historically opioids are the mainstay of drugs used to treat postoperative pain. Drugs such as morphine and fentanyl are used either as additives to local anaesthetics intrathecally or through intravenous route. Although they are effective analgesics, the side effects such as respiratory depression, nausea and vomiting will produce additional discomfort to patients. In this study we compared isobaric Levobupivacaine and isobaric Levobupivacaine with clonidine against hyperbaric Bupivacaine in patients undergoing vaginal hysterectomy. Levobupivacaine is the pure S enantiomer of racemic bupivacaine but it is less toxic to cardio vascular system and central nervous system. Intrathecal clonidine has been extensively evaluated as an alternate to neuraxial opoid for control of pain and it had been proven as a potent analgesic. Though its efficacy with hyperbaric bupivacaine has been confirmed by many trials only very few studies are available which assessed its efficacy with levobupivacaine. This is a prospective randomized control study, which was carried out in ninety patients who received subarachnoid block for vaginal hysterectomy. Ninety patients were divided into three groups namely Group B, Group LB and Group LC with thirty in each group. Control group (Group B) received 15 mg of hyperbaric bupivacaine plus 0.2ml of 0.9% normal saline, Group LB received 15 mg of isobaric levobupivacaine plus 0.2ml of 0.9% normal saline and Group LC received isobaric Levobupivacaine 15mg along with clonidine 30 micrograms. Onset and duration of sensory and motor blockade were the parameters studied along with perioperative hemodynamic changes.

160-164

Authors: Bijal M Shah, Nita D Gosai, Rashmi Ranjan Dash, Krupa D Kalaria, Bipin M Patel.

Background: Post-operative nausea & vomiting is a common and distressing complaint observed after Modified Radical Mastectomy surgery performed under General Anaesthesia. We compare the effect of combined palonosetron (0.075 mg) & dexamethasone (8mg) versus dexamethasone(8mg) administered i.v. alone for controlling post-operative nausea & vomiting in MRM Patients by means of a Randomized double blind control study. Materials & Method: In a prospective randomized study 50 patients of ASA I and ASA II undergoing elective Modified Radical Mastectomy under general anaesthesia were allocated in two groups(25 patients in each). Group A (Dexona Group) received 8 mg dexona before induction of anaesthesia. GroupB (Palonosetron +dexona Group) received IV DEX 8mg+Palonosetron 0.075 mg before induction of anaesthesia The incidence of PONV, need for rescue antiemetics and complete response was recorded at the end of 0,2,4, 6 hr,12 hrs,24 hrs. Results: The incidence of complete response (no PONV, no rescue medication) was 88% (p=0.025) for the early post-operative period (0-6 h) in the combination P+D group and 84% (p=0.032)for the late (6-24 hr) period as compared to 56% and 52% in the dexona only group in the early (0-6h) and the late (6-24h) post-operative period respectively. Conclusion: Palonosetron –DEX combined regimen given before anaesthesia induction is an effective regimen for early (0-6 hr) and late (6-24 hr) PONV with significantly lower incidence of PONV, higher incidence of complete response and better patient satisfaction.

170-178

Authors: Krishna Prabu R, Radhakrishnan A.

Introduction: Epidural opioid when combined with general anaesthesia (GA) for laparoscopy assisted vaginal hysterectomies (LAVH) effectively attenuates stress response caused by carbon dioxide (CO2) pneumoperitoneum. Moreover epidural opioids provide effective pain relief in the post-operative period. Objectives: To compare intra-operative hemodynamics and post-operative pain relief between epidural morphine and epidural buprenorphine when combined with GA for LAVH. Methods: 40 patients posted for LAVH under American Society of Anaesthesiologists (ASA) physical classification I and II were randomly allocated into two groups. Group M received 3mg morphine and Group B received 0.15mg buprenorphine with 14ml of 0.25% bupivacaine in epidural route before GA. Blood pressure and heart rate were recorded in all the patients before epidural injection, after induction of GA, after pneumoperitoneum along with trendelenburg position, every 10minutes after pneumoperitoneum and after desufflation and straightening the table. Duration of post-operative analgesia was recorded and injection tramadol in 50mg increments was used as rescue analgesia. Total tramadol consumption was also recorded in all the patients. Results: There was a statistically significant decrease in heart rate and blood pressure over time in both the groups (p<0.05). When compared between the groups there was no statistical significance (p>0.05). The duration of analgesia was significantly longer in Group M compared to Group B (p<0.05). Total tramadol consumption in Group M was significantly lesser than Group B (p<0.05). Conclusion: Epidural morphine and epidural buprenorphine are equally effective in attenuating stress response in LAVH when combined with GA. Epidural morphine provides better post-operative analgesia compared to epidural buprenorphine.

184-190

Authors: Madhavi Sanjay Chaudhari, Naresh Dilipkumar Vaswani, Birva Nimit Khara.

Introduction: For regional anesthesia, various adjuvants have been used along with local anesthetics (LA). We studied the effect of addition of Dexmeditomidine to LA in vertical infraclavicular brachial plexus block (ICB). The primary goal was to study the onset and duration of sensory and motor block. The secondary goal was to note the time for first rescue analgesic and quality of block. Materials and Method :Sixty patients ( 18 to 60 years) posted for below elbow orthopaedic surgeries were given vertical ICB using PNS, after computerized randomization into two equal groups: Group S: Bupivacaine 0.375% (18 cc) + lignocaine 1.5% 20 cc + 2cc normal saline. Group D: Bupivacaine 0.375% (18 cc) + lignocaine 1.5% 20cc +dexmedetomidine 1 μg/kg (2ml volume). All the patients were observed for onset of sensory and motor block, total sensory and motor block duration, time to first rescue analgesic and side effects if any. Results: The demographic data in two groups was statistically comparable. The onset of sensory and motor block in Group D was faster (p<0.001). The duration of sensory and motor block in Group D was longer [p<0.001].The quality of block in Group D was better (p<0.005). Conclusion: Dexmedetomidine as an adjuvant to local anesthetic agents in vertical infraclavicular block has early onset of sensory and motor blockade. The duration of sensory and motor blockade is significantly longer. The time for first postoperative rescue analgesic is also more and the quality of anesthesia as judged by the patients is better.

196-206

Authors: Avanish Bhandary, Nikhil Maruthi Pallath, Mayur Ramakrishna, Sumalatha R Shetty.

Background: The speciality of anesthesiology is closely associated with the surgical speciality and patient care peri-operatively. In spite of this, awareness of the speciality amidst patients seems to be lacking as indicated from few of the earlier studies. We planned this survey to assess the patients’ knowledge about the speciality of anesthesiology and the role of anesthesiologist in our hospital setting. Methods: In this cross sectional questionnaire based study, conducted in a tertiary care teaching hospital, 180 patients posted for elective surgery over six months were included. Structured questionnaire to identify the patients’ perception about the speciality of anesthesiology, the role of anesthesiologists inside and outside the operating room and patients’ desire for explanation of anesthesia by anesthesiologists were included. Results: In our survey, 40% of the patients did not know that anesthesiologists are in charge of anesthesia during the surgery. Among the patients’ who had previous anesthetic exposure, 69.4% felt that anesthesiologist is the doctor who is in charge of anesthesia. But, these patients’ had very little knowledge about the roles of anesthesiologist inside and outside the operating room. Interestingly 51.7% patients wanted to receive an explanation of anesthesia pre procedure by an anesthesiologist. Conclusion: The awareness of the patients’ knowledge regarding anesthesiology and the role of anesthesiologist are disappointing. The risks and responsibility by anesthesiologists actually involved in managing patients are seldom understood by the patients. Adequate measures needs to be taken to enlighten the patients about anesthesia and various responsibilities of an anesthesiologist.

214-218

Authors: Manjula Sudeep Sarkar, Pushkar M Desai, Hashim Sageer, Shubhra Sarkar.

Background: Propofol formulation containing long chain triglycerides (LCT) elicits severe pain on intravenous injection. Newer formulation of propofol containing combination of medium and long chain triglycerides (MCT/LCT;50:50) with less concentration of free propofol may be beneficial in this aspect. Methods: This prospective, randomized, double blind study included 116 ASAI/II adult patients undergoing short surgical procedures under general anesthesia. Patients in group M received 3 cc of MCT/LCT propofol (Fresofol 1%, Fresenius Kabi) and group L received LCT propofol (Diprivan 1%, Astrazeneca), both over 3 seconds (@1cc/sec to assess pain on injection using the VRS score. Induction time and requirement of additional dose of propofol was also noted. Heart rate (HR) and mean arterial pressure (MAP) were recorded at baseline, post intubation and 1, 3, 5 and 10 minutes thereafter. Serum triglyceride levels were measured 24 hours post-surgery and compared to preoperative levels. Results: Group M reported reduced pain score after IV propofol injection (1.37+2.40 vs 2.60+2.93) along with overall less incidence of pain (34.5% vs 53.4%). No difference was found in preoperative and 24 hours postoperative serum triglyceride levels in both groups. Three patients in group L developed thrombophlebitis as compared to one in group M. Induction time and hemodynamics were similar in both groups. Conclusion: MCT/LCT propofol produces less pain on intravenous injection. However, both formulations did not increase serum triglyceride levels after single induction dose.

224-232

Authors: Rama Krishna Reddy Mudiganti, Rishita Reddy Magam, Rambabu T.

Background: Haemodynamic changes such as hypertension and tachycardia due to laryngoscopy and endotracheal intubation are well known, which are not tolerated by some patients with history of Hypertension, CAD. To attenuate these responses many drugs have been tried. Aim: To compare the efficacy of IV cloridine in attenuating of haemodynamic responses during laryngoscopy & endotracheal intubation in comparison with IV plain lidocaine. Design: Randomised controlled study. Material & Method: The study includes 100 patients, randomly divided into 2 groups. Group L (50 patients) were given IV Lignocaine and Group C (50 patients) IV Cloridine was given. Statistical Analysis: Descriptive statistics and independent & paired sample ‘t’ tests. Results & Conclusion: Cloridine in the dose of 3μg/kg IV, given 15 minutes before laryngoscopy and intubation can be a better alternative than IV lidocaine 1.5mg/kg 3 minutes before laryngoscopy and intubation, in attenuating the haemodynamic responses to laryngoscopy and intubation without any side effects. In addition Cloridine also has other advantages such as decrease in the requirement of inhalational agents, desirable sedation etc.

238-242

Authors: Ahsan Mustafa, Khaja Ali Hassan, Syed Abdur Rahman.

troduction: Brachial plexus block, which involves blocking the nerve supply to upper limb, will effectively anaesthetize the upper extremity. Material & Methods: The present study of "supraclavicular brachial plexus block using Bupivacaine was carried out at Owaisi Hospital and Research Centre, Deccan College of Medical Sciences from the period of March 2015 to August 2015. A total number of 60 patients were divided into three groups of 20 patients each. The patients scheduled to upper extremity surgery were selected for the study and undergone with supraclavicular brachial plexus block. After approval from Ethical committee, study was started. Results: Combination of Lignocaine and Bupivacaine provided the advantages of rapid onset and prolonged duration of action. The short onset time due to Lignocaine minimized the waiting time for commencement of surgery and long duration of action due to Bupivacaine catered for prolonged surgery. The 100% success rate and excellent quality of block without the need for further supplementary anaesthesia gives the advantage for conducting long duration surgeries and in addition good Post operative analgesia is also achieved. Conclusions: Thus we conclude that Lignocaine and Bupivacaine combination is superior to Individual drug given alone and it combines the better qualities of both the drugs.

251-256

Authors: Vijaya Rekha Koti, Sharat Babu Chevuri, Sunil Pulla, Varunchander G.

A comparative study is done between oral Atenolol and oral Clonidine in the attenuation of cardiovascular response during laryngoscopy and intubation. 50 adult patients undergoing various elective surgeries of ASA grade 1, Mallampatigrade 1 were selected and informed consent was taken for all the cases. Patients were of both sexes and age ranging from 18 to 60 years. The study was done in two groups. Group 1 consisted of 25 patients where atenolol 0.75mg per kg body wt was given orally 3 hrs before the scheduled time of the surgery. Group 2 consisted of 25 patients where clonidine 3 micrograms per kg body wt was orally given 90min before schedules time of surgery. The drugs given in premedication were inj.glycopyrollate 10mcg/kg, inj. midazolam 40mcg/kg and inj.ondansetron 0.08mg/kg. Induction of anesthesia was achieved by inj. thiopentone in a dose of 5mg/kg iv. Tracheal intubation was facilitated with inj. suxamethonium 2 mg/kg iv.Hemodynamic parameters(BP, HR, MAP) were recorded at the intervals of Pre induction, After induction, During laryngoscopy and intubation, 1 min, 3 min, 5 min after intubation. Data was compared between the two groups of patients. Group 1 did not show a significant increase in various hemodynamic parameters. Group 2 showed higher increase in hemodynamic parameters compared to oral atenolol. Hemodynamic parameters returned to the baseline at the end of 5 min in the atenolol group whereas it took more than 5 min to return to the basal value and it has less effect on the heart rate in clonidine group compared to atenolol group. The following conclusion can be drawn from our study. Oral atenolol attenuates the increase in heart rate to laryngoscopy and intubation more effectively than oral clonidine. Oral atenolol blunts the increase in systolic, diastolic and mean arterial pressure effectively and values returned to basal value within 5 min of intubation compared to oral clonidine. No side effects were noted in atenolol and clonidine groups in our study. Hence oral atenolol in a dose of 0.75 mg/kg given 3 hrs before induction of anaesthesia is effective in attenuating hemodynamic response to laryngoscopy and endotracheal intubation when compared to oral clonidine.

261-270

Authors: Subramanian R, Vijay Narayanan S, Mohamed Mubarack A, Rajalekshmi M.

Background: Ropivacaine, the pure S enantiomer of propivacaine, due to its less lipophilicity than bupivacaine does not produce cardiotoxicity or neurotoxicity and causes less motor blockade. Dexmedetomidine the newer selective alpha 2 adrenergic agonist has several advantages when given through epidural route as a neuraxial adjuvant. Aim: To compare 0.75% Inj.Ropivacaine with Inj.Fentanyl and 0.75% Inj.Ropivacaine with Inj.Dexmedetomidine epidurally for the duration of analgesia, hemodynamic changes, degree of motor blockade and occurrence of side effects. Materials and Methods: 60 patients undergoing lower limb orthopaedic surgeries were randomized to two groups. Group RF (n=30) received 0.75% Inj.Ropivacaine 20 cc with Inj.Fentanyl 50 mcg whereas Group RD (n=30) received 0.75% Inj.Ropivacaine 20 cc with Inj.Dexmedetomidine 50 mcg in normal saline diluted upto 1cc. Quality of sensory block, motor block, pulse rate, blood pressure, pain assessment and any adverse outcome were noted. Statistical analysis was done by student’s paired t-test for intragroup comparison and unpaired t-test for intergroup comparison and p<0.05% was taken to be significant. Results: Dexmedetomidine fastens the onset of analgesia, prolongs the duration of analgesia thereby reducing the doses of rescue analgesics post operatively, improves the quality of motor blockade without aggravating changes in haemodynamic parameters and has less adverse effects. Conclusion: We conclude that dexmedetomidine serves as a good neuraxial adjuvant when added to 0.75% ropivacaine in epidural anaesthesia given for lower limb orthopaedic surgery

278-282

Authors: S. Shivakumar, K. Harikaran.

Background and Aim: Exchange of the endotracheal tube (ETT) with laryngeal mask airway (LMA) before emergence from anaesthesia and use of dexmedetomidine due to its anxiolytic, analgesic qualities and less respiratory depressant effects , reduced the complications during extubation with better surgical outcome especially in otolaryngology surgeries. Aim of this randomized-prospective study is to compare the effectiveness of ETT/ ambu laryngeal mask ALMA) exchange and dexmedetomidine for smooth extubation in patients undergoing elective tympanoplasty. Methods and Materials: 60 patients undergoing elective tympanoplasty under general anaesthesia were randomly divided into two groups- 30 patients in each group. Group I: ALMA (ambu laryngeal mask airway) used for ETT/LM exchange Group II: Dexmedetomidine 1.0 mcg/kg given 10 minutes before the end of surgery. Results: In group I patients 28 pateints and 27 patients in group II had smooth extubation. All cases in Group I and Group II maintained a regular respiratory pattern during the study without desaturation and maintaining adequate tidal volume. There was insignificant difference in hemodyamic parameter between the groups. Conclusion: ETT/ALMA exchange and dexmedetomidine 1.0 μg/kg along with sevoflurane produced smooth emergence in patients undergoing elective tympanoplasty surgery

287-291

Authors: Anurag Agarwal, Vipin Kumar Dhama, Subhash, Yogesh Kumar Manik, Shantanu Kumar Das.

Background & Objectives: This study was done to assess the feasibility of thoracic epidural anaesthesia in open cholecystectomy. Laproscopic cholecystectomy is the standard now a days but in developing countries open cholecystectomy is still commonly performed. Methods: Our study was carried out on 60 adult, non-pregnant patients ASA grade I, II between 18 – 60 years of age for elective open cholecystectomy under thoracic epidural anaesthesia & general anaesthesia. Haemodynamic parameters(BP, heart rate), oxygenation were observed for 60 minutes. Sensory & motor blockade were observed in thoracic epidural group. Results: In our study both group T and group G were statistically comparable in terms of their gender, mean age and mean weight. Base line pulse rate, SBP, DBP, MAP was comparable in both groups. However, there was significant statistical difference in the two groups in hemodynamic parameters in the study period but it was not clinically significant. Interpretation & conclusions: Thoracic epidural anaesthesia can be used for open cholecystectomy in ASA 1, 2 patients. It provides hemodynamic stability, minimal respiratory distress (as per spo2 values). General anaesthesia still remains the anaesthetic technique of choice for open cholecystectomy. However, an experienced anaesthetist can use thoracic epidural anaesthesia for open cholecystectomy.

300-315

Authors: Vidushi S, Devesh S, Asrar M, Meenaxi S, Anumeha J.

Background and Objectives: The present study was conducted to compare the efficacy of Pre-treatment with a low dose of intravenous ephedrine 70 μg kg-1 on the intubating conditions and its effects on hemodynamic during rapid tracheal intubation using propofol 2.5 mg kg-1 and rocuronium bromide 0.6 mg kg-1. Methodology: In this study one hundred patients were included and randomly divided into two equal groups which received either ephedrine 70 μg kg-1 diluted to 5 ml with normal saline (Group EPR) or 5 ml of normal saline (Group SPR) 3 min prior to laryngoscopy and intubation with Propofol 2.5 mg kg-1 and rocuronium bromide 0.6 mg kg-1. A blinded anaesthesiologist assessed the intubating conditions; heart rate and mean arterial pressure before anaesthesia induction (baseline), and every minute thereafter till5 minutes post intubation. A 30% change in hemodynamic variables from baseline was regarded as clinically significant. Data were analyzed using Paired samples t-test. Results: Intubating conditions were better (p=0.023) in the ephedrine pre-treated group. There was no statistically significant difference between the ephedrine pre-treated group and control regarding the time taken for laryngoscopy and intubation. There were no significant hemodynamic changes between the two groups except tachycardia. Conclusion: Ephedrine 70 μg kg-1 prior to induction with propofol 2.5 mg kg-1 improves intubating conditions compared to propofol alone 1 minute after 0.6 mg kg-1 rocuronium bromide injection without significant hemodynamic effects.