Indian Journal of Clinical Anaesthesia

424-427

Authors: Manoj Kumar Giri, BK Rao, Aman Ohri, LS Mishra

Introduction: Sevoflurane, and Propofol are widely used for anesthesia during intracranial surgery. All these drugs reduce the cerebral metabolic rate (CMR) for oxygen (CMRO2). In contrast to their similar effect on cerebral metabolism, they have different effects on cerebral blood flow (CBF). Accordingly, the purpose of our study was to determine the jugular bulb venous blood oxygen saturation (SjO2) as a measure of the flow metabolism ratio under propofol & sevoflurane anesthesia in patients with intracranial mass lesions. Objectives: To compare the effects of Sevoflurane & Propofol on jugular bulb oxygen saturation with the help of evaluation of arterial and jugular bulb venous blood samples for hemoglobin (Hb), hematocrit, and blood gas analysis using automated blood gas analyzer & Calculation of arterial to jugular bulb venous oxygen content differences (AJDO2). Materials and Method: The proposed study is being carried out in S.R.N. Hospital associated with M.L.N. Medical College, Allahabad after obtaining clearance from the Ethical Comittee. A total of 40 patients were included in the study, of ASA Grade 1 & 2, who after randomisation were divided into 2 groups of 20 each, receiving Propofol & Sevoflurane respectively. Statistical Test: Data was analysed using unpaired t test with the help of SPSS software. Results: Propofol when compared with Sevoflurane, decreased Jugular Bulb Oxygen saturation (SjO2) & this difference was statistically significant(49.25±6.57 Vs. 55.60±3.33), decreased PjO2(28.9±2.31 VS 33.15±2.08) & increased AjDO2 (6.62±1.70 VS 5.75±0.81) to a more significant level(p value < 0.05).Further details will be discussed later in the presentation. Conclusion: In conclusion, brain tumor patients under propofol anesthesia, showed SjO2 and PjO2 levels that were significantly lower than those in patients under Sevoflurane anesthesia. Thus in brain tumour patients, in the already compromised brain tissue it is advisable to use Sevoflurane for maintenance of anaesthesia so as to preserve the flow metabolism ratio.

435-440

Authors: Basappa M. Diwanmal, Jyotsna Paranjpe, Vikas Kumar, K. Sri Hyndavi.

Introduction and Objective: The neuraxial anesthesia presents several advantages over general anesthesia, however hypotension and bradycardia are the inevitable consequences of spinal anesthesia (SA). In fear of fall in perfusion of vital organs like kidney, it is a common practice to administer drugs to prevent the hemodynamic changes after SA. Herewith, we have tried to evaluate the need of pharmacotherapy to prevent hemodynamic effects after subarachnoid block. Materials and Method: Total 120 adult patients of ASA physical status I/II admitted in a tertiary care center for elective surgeries on lower abdomen and lower limb were selected for the study. They were randomly divided into 2 equal groups. Group I (control group) received 1 cc of water for injection while Group II (study group) received 1cc (inj. Atropine 0.3 mg + inj. Ephedrine hydrochloride 5 mg) intravenously 10 min after giving spinal anesthesia. Confounding variables like volume of fluid administered, positioning and sensory level were reduced to minimum. Hemodynamic variables like heart rate, systolic, diastolic, mean blood pressure, spO2 were recorded at 5 minute intervals up to 2 hrs after commencement of spinal anaesthesia. Urine output was recorded by urometer and the values were noted every 30 min, adverse reactions were noted by a blinded observer. Observation and Results: The demography and types of surgeries for both the groups were comparable. Heart rates and blood pressures dropped down after giving SA. Though variation between two groups was statistically significant, at the end of 2 hours they resumed baseline levels. There was no adverse effect on urine output and incidence of adverse effects in both the groups was comparable. Conclusion: It is not necessary to use preventive pharmacotherapy to counterbalance hemodynamic changes occurring after subarachnoid block.

447-452

Authors: Geeta Karki, Vishwadeep Singh.

Introduction: In general anaesthesia, induction of patients with intravenous anaesthetic agents is a common practice. Induction is a very crucial time as at this time the patient is liable to undergo sudden unexpected haemodynamic changes due to the exaggerated physiological effects of the induction agents. Anaesthetist all the time needs to choose an agent with least adverse effects for the safety of the patient. Aim and Objective: In this study, our objective was to observe the effects of propofol and etomidate on the haemodynamics during induction of general anaesthesia. Materials and Method: The study included 60 ASA Grade I and II patients aged between 18 and 60 years who were given general anaesthesia for elective surgery. The patients were allocated to two groups randomly with 30 patients in each group. Patients induced with propofol 2mg/kg were assigned to Group P and those induced with etomidate 0.3 mg/kg were assigned to Group E. The groups were compared for the changes in systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP)* The data collected was statistically analysed using the computer software SPSS. A “p” value of 0.05 or less was considered as statistically significant. Observation and Results: It was observed that in Group P after induction with the study drug there was a significant decrease in the haemodynamic parameters – systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) as compared to the parameters before induction (p ≤ 0.05). On the other hand in Group E the post induction values of haemodynamic parameters were not statistically different than the values before induction (p ≥ 0.05). Conclusion: Thus from our study, we came to the conclusion that etomidate when used for induction of general anaesthesia offers greater stability of haemodynamics than propofol and hence can be preferred as the agent of choice for induction of patients and especially more so for those with cardiac disease in whom stable haemodynamics are all the more important.

459-462

Authors: Juhi Saran, Priyank Srivastava, Geeta Singh.

Introduction: With the introduction of epidural anaesthesia, it is being widely used for abdominal surgeries and lower limb surgeries and mainstay for providing postoperative analgesia. With the development of enantiomers of Bupivacaine (Levobupivacaine and Ropivacaine), epidural anaesthesia is being used widely with less complications. Purpose: To compare the block characterstics and duration of analgesia of Bupivacaine 0.5% and Levobupivacaine 0.5% in lower limb surgeries. Materials and Method: After obtaining ethical committee approval and informed written consent from patients, the study was carried out on 70 patients of either sex, between 18 to 65 years of age. Patients were divided in two groups Group B( Bupivacaine) and Group L(Levobupivacaine) and 20 ml of study drug given in each group. Result: The Sensory block onset time between group B & L was highly significant. P value ≤0.001. Whereas the Motor block onset time between B & L was not significant (P value= 0.305). The duration of motor (P value = 0.892) and sensory block (P value = 0.659) between both group was not significant. The difference in the time of regression among the group B & L was highly significant in respect of motor and sensory the parameters P<0.001.There was marked difference in the duration of analgesia between the patients of Group B & L. P= 0.026 Conclusion: Thus from our study we can conclude that Onset of Sensory & motor block for Levobupivacaine was longer as compared with Bupivacaine. The highest sensory level of T7 segment was found to be with Group B then Group L.

469-471

Authors: Manish Khandelwal, Amit Kulshrestha, Priyanka Saini, Meenaxi Sharma.

Introduction: In this randomized, double-blind study we evaluated the relative efficacy of palonosetron (a new, selective 5hydroxytryptamine [5-HT3] receptor antagonist) and ondansetron in preventing postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy surgery. Materials and Method: Patients were given either palonosetron 0.075 mg (n = 50) or ondansetron 8 mg (n = 50) intravenously, just before anaesthesia. The occurrence of nausea and vomiting and the severity of nausea according to a visual analogue scale were monitored immediately after the end of surgery and during the following 24 hour post surgical period in time intervals of 0-4,4-8,8-12 and 12-24 hour period. Result: The incidence of PONV and nausea (not vomiting) was significantly lower in the palonosetron group than in the ondansetron group during the 24 hour post surgical period (P < 0.05). More patients in the palonosetron group had a complete response (no PONV and no need of rescue antiemetic) compared with the ondansetron group. The need for rescue antiemetics was significantly lower in the palonosetron group than in the ondansetron group during the 24 hour post surgical period (P <0.05). The severity of nausea (VAS) and incidence of adverse effects were not significantly different between the two groups. The incidence of PONV was significantly lower in the palonosetron group compared with the ondansetron group (32% vs 56%, respectively). Conclusion: Palonosetron 0.075 mg was more effective than ondansetron 8 mg in preventing postoperative nausea and vomiting (PONV).

476-479

Authors: S. Mahalakshmi, VJ Karthik, NV Madhava Krishna, A. Niranjan Kumar.

Introduction: A perfect setting for tracheal intubation include a rapid onset, and short duration of action. These requirements are best met by succinylcholine, an ultrashort acting depolarizing muscle relaxant. However its many unwanted side effects have necessitated a search for an alternative drug. Rocuronium bromide is a steroid, non-depolarizing neuromuscular blocking agent with a rapid onset and an intermediate duration of action. It may be a suitable alternative to succinylcholine. Aim of Study: To study and compare the efficacy of rocuronium bromide in two dosage schedules – 0.6mg / kg (2 x ED95) and 0.9mg / kg (3 x ED95) IV, with succinylcholine chloride 1.5mg / kg IV in patients with respect to: 1. Intubating conditions at one minute 2. Onset of action 3. Adverse effects Materials and Method: This study was conducted at Government Stanley Hospital, Chennai, in the patients undergoing general surgical procedures. After institutional approval and informed consent, 60 patients were enrolled in the study. Group A: Succinylcholine 1.5 mg/kg (Sch 1.5) Group B: Rocuronium bromide 0.6 mg/kg (2 x ED 95)(Roc 0.6) Group C: Rocuronium bromide 0.9 mg/kg (3 x ED 95)(Roc 0.9) Anaesthesia was induced with Thiopentone sodium 5mg/kg over a period of 20 seconds. The ulnar nerve was stimulated at the wrist using 0.1 Hz single twitch stimulation mode and the supramaximal current was determined. Once a control twitch height was established the bolus of randomly assigned neuromuscular blocking agent was administered intravenously in less than 5 seconds. When injection was completed, a timer was started and after 20 seconds the ulnar nerve was stimulated using single twitch mode at a frequency of 1 Hz. At one minute, intubation was performed and scored by a blinded experienced anaesthesiologist. anaesthesia was maintained with Nitrous oxide, oxygen and Neuromuscular blocking agents. Results and Observations: Vocal cord relaxation is comparable between group a and c. Excellent intubating conditions was seen with Group A (Sch 1.5mg/kg) with 100% score. Excellent intubating conditions with Group B (Roc 0.6 mg/kg) and Group C are 30% and 85% respectively. P value of Succinylcholine 1.5 mg/kg and Rocuronium 0.9 mg/kg is 0.466 statistically not significant. Conclusion: Succinylcholine is an ideal agent for intubation in all surgical procedures. Intubating conditions of Rocuronium bromide at a dose of 0.9mg/kg (3xED95) is comparable to Succinylcholine 1.5mg/kg at 1minute.Rocuronium bromide 0.9 mg/kg can be used safely in patients where Succinylcholine is contraindicated.

484-488

Authors: Sandipbhai Jivanbhai Patel, Rajesh Dyanoba Subhedar

Introduction: The use of local anaesthesia and intravenous sedation for middle ear surgeries is long established and has many advantages. Good sedation is mandatory to alleviate different discomforts associated with these surgeries under local anaesthesia. Opioid- benzodiazepine sedation is common technique used for many procedures. Both pentazocine and nalbuphine are nalorphine like opioid agonist antagonist drugs. This study was undertaken with an aim to compare two opioid-benzodiazepine sedative techniques, ‘pentazocine-diazepam’ and ‘nalbuphine-diazepam’ for middle ear surgery under local anaesthesia. Materials and Method: Sixty patients scheduled for elective middle ear surgery between 15 to 50 years age group, of either sex having American society of anaesthesiologists physical status of 1 or 2 were included in the study to receive either pentazocine-diazepam (Group A) or nalbuphine-diazepam (Group B) sedation along with local anesthesia. Results: Ramsay sedation score was satisfactory and comparable in both groups. Respiratory and spo2 changes were safe and comparable in both groups. Intra operative discomforts were minimal and easily manageable in both groups. Analgesic efficacy was good with nalbuphine having statistically significant longer duration of post operative analgesia than pentazocine (p less than 0.00001). Post operative side effects were minimal and comparable in both groups. Conclusion: Both regimens gave satisfactory results in terms of sedation, analgesic efficacy, respiratory and spo2 changes with minimal discomforts and nalbuphine being superior in terms of post operative analgesic dur

494-497

Authors: Senthil Kumar VS.

Introduction and Objective: Several techniques and modifications have been to put forward to decrease the decrease nasopharyngeal trauma and epistaxis. This study evaluated the effect on partial inflation of the thermo softened endotracheal tube cuff to reduce bleeding. Materials and Method: This observational study was done at IRT Perunthurai Medical college Hospital after the institutional ethical committee approval between April 2013 and August 2013 at the main operating theater complex. 20 patients who were scheduled for open reduction and internal fixation of mandible that required nasal intubation were chosen following a formal written informed consent. Nasal pharyngeal anatomy was screened by an ENT surgeon and noted accordingly as a part of pre-anaesthetic assessment for adequate nasal patency. In the operating room after nasal decongestion and lubrication appropriate thermo softened tube is introduced in the preferred nostril with the cuff inflated with a minimal volume of air not exceeding 2 milliliters. Ease of passage of the endotracheal tube, degree of bleeding during laryngoscopy and post-operative nasal pain were observed by the anaesthesiologist who performed the laryngoscopy and Magill forceps assisted nasotracheal intubation. Results: When observed the bleeding ranged from a thin to a thick streak which indicated that there is definitive reduction in the amount of trauma induced by the passage of the inflated thermo softened endotracheal tube with minimal cuff inflation. Conclusion: Partial inflation of the cuff in a thermo softened tube was found to be very effective in reducing the nasopharyngeal trauma thereby significantly decreased the incidence of epistaxis and its related complication

503-507

Authors: Venkatesh Murthy KT, Rupakala BM, Sangeetha C, Asha G, Maya D. Nadakarni.

Register Oxytocin is routinely administered during caesarean delivery to initiate uterine contraction and thus decrease the blood loss from the site of placental attachment. Adverse effects are known to occur after I.V. oxytocin administration, depending on the dose and rate of administration. The aim of our study was to compare the effect of oxytocin intravenous bolus +I.V. infusion with oxytocin I.V. infusion alone in maintaining adequate Uterine Tone and Hemodynamic stability in women undergoing elective caesarean delivery. Sixty parturients undergoing caesarean delivery under spinal anesthesia were recruited for our study. They were randomly allocated to receive 3IU of oxytocin as bolus intravenous injection over 15 seconds followed by I.V. infusion of oxytocin at 0.125 IU/min (group B) or placebo followed by I.V. infusion of oxytocin at 0.125 IU/min over 4 hours (group I). Uterine tone was assessed as adequate or inadequate by the attending obstetrician. Intraoperative heart rate, non-invasive blood pressure, amount of blood loss, and any complications were recorded. Postoperatively they were followed for 24 hours for any complications. Results: There was significant rise in heart rate and significant decrease in mean arterial pressure in bolus group compared to infusion group. There was no significant change in the amount of blood loss between the groups. Only one incidence of vomiting occurred in the infusion group. There was a gradual and adequate rise in Uterine tone in both the groups by 15th minute post oxytocin. Conclusion: Infusion of oxytocin raises the uterine tone gradually compared to bolus group. Bolus group shows significantly more adverse cardiovascular events.

512-517

Authors: M. Kamalakannan, P. Sunder.

The present study is to compare the "Timing principle" and the "Priming principle" for tracheal intubation using rocuronium during balanced anesthesia by assessing the Intubating conditions and Hemodynamic changes during intubation. The succinylcholine is considered to be the best drug for rapid tracheal intubation because of its rapid onset and ultrashort duration of the action. The “priming technique” uses a sub-paralyzing dose of non-depolarizing muscle relaxant where 20% of ED 95 or 10% of the intubating dose was administered 2 to 4 min before administering an intubating dose. This technique has been proved to accelerate the onset of action by 30 to 60 seconds.(5) In “timing principle” a single bolus of non-depolarizing muscle relaxant was given followed by the administration of the induction agent after the first sign of the onset of clinical weakness. The “high – dose regimen” was used when tracheal intubation has to be accomplished in less than 60 – 90 seconds.(6) The study was conducted in Madras Medical College, Chennai The groups were comparable based on age and weight. Males were more in Group RP. Using the “Timing principle” with rocuronium 0.6 mg/kg consistently provides good to excellent intubating conditions at 60 seconds after the induction of anesthesia. Using the "Priming principle" with rocuronium 0.06 mg/kg followed by rocuronium 0.54 mg/kg consistently provides fair to good intubating conditions at 60 seconds after induction of anesthesia.

523-529

Authors: Narender Kaloria, Indu Mohini Sen, Vikas Saini, Rajesh Gupta, Rama Walia.

Introduction: Post-operative nausea and vomiting (PONV) is associated with wound dehiscence, pulmonary aspiration, electrolyte disturbances, delayed recovery and patient dis-satisfaction. The present study was aimed to compare antiemetic efficacy of intravenous palonosetron with dexamethasone versus ondansetron with dexamethasone to prevent PONV in patient undergoing laparoscopic sleeve gastrectomy (LSG). Materials and Method: Prospective, double blind randomized study of 24 morbidly obese patients planned for LSG. Preoperative gastric emptying scintigraphy (GES) done to know about gastric emptying. All patients premedicated with tablet ranitidine 150 mg a night before and 2 hours before surgery. Patients randomized into two groups PD (n=12) and OD (n=12) according to antiemetic agents used 30 min prior induction. Perioperative hemodynamic parameter were measured every 10 min interval during intraoperative and incidence of PONV along with hemodynamic parameters were assessed at arrival 0, 6, 12, 24, 48 and 72 hours postoperative period. Observation and Results: Demographic data, perioperative hemodynamic parameters were well matched. The overall incidence of nausea/vomiting was 54.6%/18.2% and 63.6%/18.2% in group PD and group OD; respectively during 72 hours follow-up. The total dose of rescue antiemetic was 10 mg in group PD and 11.67 in group OD (p=3.14). GES done in 8 patients (PD; 3 and OD; 5) indicated normal gastric emptying and only one patient had PONV in this subset. Conclusions: In this preliminary study, palonosetron and ondansetron in combination with dexamethasone had comparable antiemetic efficacy after LSG. Further studies can be conducted to find-out the role of preoperative GES as a tool to predict PONV.

536-538

Authors: Mamta Dubey, Nitesh Goel, Itee Choudhary, Lalit Gupta.

Video laryngoscopes are the latest addition in an anaesthesiologist’s armamentarium. They are comparable to fiberoptic bronchoscope in terms of ease of visualization of vocal cords especially in awake intubation and in those with difficult airway. They have an added advantage of having an easier learning curve than fiberoptic bronchoscope guided intubation. There are several studies where video-laryngoscopes have been used in manikins and normal patients for intubation in both supine and lateral position successfully. Of these C-Mac D-Blade laryngoscope has an added advantage of having a blade like Macintosh with camera at the tip which gives good results. In our case report we describe an emergent scenario of successful awake nasal intubation in lateral position using C-Mac D-blade laryngoscope in a patient with documented difficult intubation.