Post-operative vomiting after pediatric strabismus surgery: A comparison of propofol versus sevoflurane anaesthesia.

Background and Aims: Squint surgery is a risk factor for postoperative vomiting (POV) in children. This study was designed to compare the incidence of POV in children undergoing strabismus surgery under balanced anesthesia with sevoflurane versus intravenous anesthesia with propofol. Material and Methods: In this prospective randomized controlled study conducted in a tertiary care ophthalmology hospital, 70 ASA I-II children aged 1-12 years undergoing strabismus surgery were randomized to two groups -Group S (sevoflurane-based anesthesia) and Group P (propofol-based anesthesia) for maintenance. The surgical details, intraoperative hemodynamic parameters, recovery characteristics, and emergence delirium were recorded. Any episode of postoperative vomiting in the 0-2 hours, 2-6 hours, and 6-24 hours period was noted. Rescue antiemetic was administered if there was more than one episode of vomiting. Results: Both the groups were similar with respect to demographic and surgical details. The average duration of surgery was 118.2 ± 41.88 min in group S and 137.32 ± 39.09 min in group P (P = .05). Four children in group S (11.4%) and one child in group P (2.9%) had POV in the first 24 hours but this was not statistically significant (P = .36). The median time to discharge from post anesthesia care unit was significantly less (P = .02) in the P group (50 min) than in the S group (60 min). Conclusion: Propofol-based anesthesia does not offer advantage over sevoflurane, in reducing POV after squint surgery, when dual prophylaxis with dexamethasone and ondansetron is administered. It, however, reduces the duration of stay in the post anesthesia care unit.

Median effective dose of intranasal dexmedetomidine for satisfactory mask induction in children undergoing examination under anaesthesia for retinoblastoma - A prospective up and down sequential allocation study.

Background and Aims: Inhalational technique is used to induce anaesthesia in children without intravenous access. We aimed to determine the median effective dose (ED50) of intranasal dexmedetomidine to ensure satisfactory mask acceptance during inhalation induction in children with retinoblastoma undergoing examination under anaesthesia. Methods: A prospective sequential allocation study was conducted in children aged 1-60 months divided into Group A (1-18 months) and Group B (18-60 months). Children were administered dexmedetomidine intranasally as premedication. Sedation was assessed using the modified Observer Assessment of Alertness and Sedation Scale until induction. Successful mask acceptance was defined as a cooperative or asleep child during inhalational induction. The starting dose of dexmedetomidine was 1 µg/kg. The next dose varied by 0.2 µg/kg depending on the outcome of this case. According to the Dixon up-and-down method, the mean of midpoints of the failure-success sequence was calculated to obtain the ED50 values. Results: The ED50 of intranasal dexmedetomidine for satisfactory mask acceptance was 0.7 µg/kg (95% confidence interval [CI]: 0.54-0.86) in Group A (n = 23) and 0.96 µg/kg (95% CI: 0.83-1.08) in Group B (n = 25) (P = 0.020). The mean (standard deviation) duration of anaesthesia was 33.5 (14.9) minutes in group A versus 23.5 (8.48) minutes in Group B (P = 0.007). Conclusion: ED50 was lower in children younger than 18 months than in older children. There was no difference in the time to discharge from the post-anaesthesia care unit despite the procedure being longer in smaller children.

Effect of adding dexmedetomidine to 0.75% ropivacaine in peribulbar block for vitreoretinal surgery.

Background and Aims: Peribulbar anesthesia is suitable for vitreoretinal (VR) surgery. Dexmedetomidine has been used in peribulbar block (PBB) to improve akinesia and analgesia. We aimed to study the efficacy of adding dexmedetomidine to 0.75% Ropivacaine in PBB for VR surgery. The primary outcome was the requirement of block supplementation and secondary outcome was post-operative analgesic requirement. Material and Methods: 100 adult patients undergoing VR surgery were included in this prospective randomized double-blinded controlled study. The composition of the drug used for PBB in the 3 groups was Group R (8 ml of 0.75% Ropivacaine +0.5 ml normal saline (NS)), Group D25 (8 ml of 0.75% Ropivacaine +25µg Dexmedetomidine) and Group D50 (8 ml of 0.75% Ropivacaine +50 µg Dexmedetomidine). Results: The groups were comparable in terms of patient demographics. The requirement for block supplementation was 16.7% in Group R (5/30), 12.5% in Group D25 (4/32) and 8.8% in group D50 (3/34) (P = 0.64). The mean time to first request for post-operative analgesia was432 ± 362 min in Group R, 572 ± 339 min in Group D25 and 614 ± 394 min for Group D50 (P = 0.26). There was significant difference in the heart rate (P = 0.047), mean arterial pressure (P = 0.012) at 30 min and sedation (RASS) score at 15, 30, 60 (P < 0.001) and 120 (P = 0.019) min between the D50 and group R. Patients undergoing buckling procedures had significantly shorter time to request for analgesia (P = 0.003). Conclusion: Addition of dexmedetomidine does not offer advantage over 0.75% Ropivacaine in PBB for vitrectomy. Its benefit in more painful procedures like scleral buckle needs further validation.

Improved accuracy of S-value-based dosimetry: a guide to transition from Cristy-Eckerman to ICRP adult phantoms.

BACKGROUND: In 2016, the International Commission on Radiological Protection (ICRP) published the results of Monte Carlo simulations performed using updated and anatomically realistic voxelized phantoms. The resulting specific absorbed fractions are based on more realistic human anatomy than those computed in the stylized, geometrical Cristy-Eckerman (CE) phantom. Despite this development, the ICRP-absorbed fractions have not been widely adopted for radiopharmaceutical dosimetry. To help make the transition, we have established a correspondence between source and target tissues defined in the CE phantom and those defined in the ICRP phantoms. RESULTS: The ICRP phantom has 79 source regions and 43 target regions in comparison with the 23 source and 18 target tissue regions defined in the CE phantom. The ICRP phantom provides tissue regions with greater anatomical detail. Some of this additional detail is focused on radiation protection and dosimetry of inhaled/ingested radioactivity. Some, but not all, of this detail is useful and appropriate for radiopharmaceutical therapy. We have established the correspondence between CE and ICRP phantom source and target regions and attempted to highlight the ICRP source tissues relevant to radiopharmaceutical therapy (RPT). This paper provides tables and figures highlighting the correspondences established. CONCLUSION: The results provide assistance in transitioning from CE-stylized phantoms to the anatomically accurate voxelized ICRP phantoms. It provides specific guidance for porting the total absorbed activity for regions as defined in the CE phantom to regions within the ICRP phantoms.

Olecranon Bursitis Secondary to Trauma.

The authors present a case of traumatic olecranon bursitis, initially presumed to be cellulitis. The clinical presentation, diagnosis, and management are discussed.

Comparison and evaluation of single-use LMA supreme versus the reusable proseal LMA in paralyzed patients undergoing surgery with controlled ventilation.

BACKGROUND AND AIMS: The objective of this prospective randomized blinded study was to assess the safety and efficacy of the laryngeal mask airway (LMA) Supreme as compared with the LMA Proseal. MATERIAL AND METHODS: A total of 60 patients were randomised into two groups to either receive a Proseal LMA (PLMA) or Supreme LMA (SLMA) for airway management. The primary outcome was to measure oropharyngeal leak pressure (OLP) in both groups. The secondary outcomes were the measurement of insertion time, insertion success rate, fibreoptic grading, intracuff pressure, ease of ventilation, and airway pressure on standard ventilatory settings and postoperative complications. RESULTS: Intracuff pressure increase after 60 minutes of induction was significantly higher in the PLMA group (PLMA 97.43 ± 11.03 cm of H2O and SLMA 75.17 ± 8.95 cm of H2O). OLP was recorded after device insertion, after 30 min and after 60 min in each group and was found to be 28.71 ± 2.97, 30.93 ± 2.87, and 31.93 ± 2.72 cm of H2O in PLMA and 24.84 ± 2.08, 26.73 ± 2.26, and 27.95 ± 2.55 cm of H2O in SLMA group, respectively. The mean OLP with the SLMA was significantly (p=<.001) lower than PLMA. All the other parameters were comparable in both groups. CONCLUSION: PLMA is better than SLMA as airway device to ventilate at higher airway pressure in paralyzed adult patients. On the basis of our study, we recommend Proseal over Supreme LMA.

Predicting endotracheal tube size from length: Evaluation of the Broselow tape in Indian children.

BACKGROUND AND AIMS: Several formulae are available to estimate endotracheal tube (ETT) size in children. This study was designed to compare the ETT estimated by the Broselow tape (BT) with age-based estimation of ETT size and to identify the most accurate formula for the prediction of uncuffed ETT size in Indian children. MATERIAL AND METHODS: Pediatric patients aged 1 month-6.5 years undergoing emergency or elective surgery under general anesthesia requiring endotracheal intubation with uncuffed ETT were included in this study. The ETT size was selected based on the age formula (Penlington formula). The ETT used was deemed to be of correct fit based on the delivery of adequate tidal volume and presence of minimal leak at 20 cm H2O. The actual ETT used was compared with that predicted by age, length of the child, BT, and fifth fingernail width of the child using Pearson's correlation. RESULTS: In children aged <6 months, the ETT used was found to correlate with length (r = 0.286, P = 0.044) and finger nail width (r = 0.542, P < 0.001) of the children. In children >6 months, the ETT used correlated with that predicted from age, BT, length, and fingernail width of the children. In our study, BT has an overall correct predictability rate of 50.3% whereas the age-based formula has a correct prediction rate of 59.8% and length-based formula is 48.7% accurate. CONCLUSION: Length of the child has a good correlation with size of the ETT to be used in Indian children across all age groups. BT is an effective tool to predict ETT size in children >6 months.

A randomized trial evaluating low doses of propofol infusion after intravenous ketamine for ambulatory pediatric magnetic resonance imaging.

OBJECTIVE: Our study compared the discharge time after pediatric magnetic resonance imaging (MRI) following sedation with propofol infusion dose of 100, 75 and 50 mcg/kg/min given after a bolus dose of ketamine and propofol. MATERIALS AND METHODS: One hundred children of American Society of Anesthesiologists status 1/2, aged 6 months to 8 years, scheduled for elective MRI were enrolled and randomized to three groups to receive propofol infusion of 100, 75 or 50 mcg/kg/min (Groups A, B, and C, respectively). After premedicating children with midazolam 0.05 mg/kg intravenous (i.v.), sedation was induced with bolus dose of ketamine and propofol (1 mg/kg each) and the propofol infusion was connected. During the scan, heart rate, noninvasive blood pressure, respiratory rate, and oxygen saturation were monitored. RESULTS: The primary outcome that is, discharge time was shortest for Group C (44.06 ± 18.64 min) and longest for Group A (60.00 ± 18.66 min), the difference being statistically and clinically significant. The secondary outcomes that is, additional propofol boluses, scan quality and awakening time were comparable for the three groups. The systolic blood pressure at 20, 25 and 30 min was significantly lower in Groups A and B compared with Group C. The incidence of sedation related adverse events was highest in Group A and least in Group C. CONCLUSION: After a bolus dose of ketamine and propofol (1 mg/kg each), propofol infusion of 50 mcg/kg/min provided sedation with shortest discharge time for MRI in children premedicated with midazolam 0.05 mg/kg i.v. It also enabled stable hemodynamics with less adverse events.

When place and time matter: How to conduct safe inter-hospital transfer of patients.

Inter-hospital transfer (IHT) of patients is often needed for diagnostic or therapeutic interventions. However, the transfer process carries its own risks as a poorly and hastily conducted transfer could lead to adverse events. In this article, we have reviewed literature on the key elements of IHT process including pre-transfer patient stabilization. We have also discussed various modes of transfer, physiological effects of transfer, possible adverse events and how to avoid or mitigate these. Even critically ill-patients can be transported safely by experienced and trained personnel using appropriate equipment. The patient must be maximally stabilized prior to transfer though complete optimization may be possible only at the receiving hospital. Ground or air transport may be employed depending on the urgency, feasibility and availability. Meticulous pre-transfer check and adherence to standard protocols during the transfer will help keep the entire process smooth and event free. The transport team should be trained to anticipate and manage any possible adverse events, medical or technical, during the transfer. Coordination between the referring and receiving hospitals would facilitate prompt transfer to the definitive destination avoiding delay at the emergency or casualty. Documentation of the transfer process and transfer of medical record and investigation reports are important for maintaining continuity of medical care and for medico-legal purposes.

Anaesthetic management of parturient with acute atrial fibrillation for emergency caesarean section.

A 31-year-antenatal lady with critical mitral stenosis presented for emergency caesarean section with fetal distress. She had acute onset atrial fibrillation. She was given a combined spinal epidural (CSE) anaesthesia and her arrhythmia was successfully managed after delivery of the baby with intravenous calcium channel blocker. Mitral stenosis is the most common valvular heart disease complicating pregnancy in developing countries. The physiological changes during pregnancy may exacerbate their cardiac symptoms. They may present with complications like congestive cardiac failure, atrial fibrillation, or pulmonary thromboembolism during the antenatal, intrapartum, or postpartum period. Here we discuss the management of parturient woman with high maternal and fetal risk presenting for emergency caesarean. The merits of regional anaesthesia and the importance of invasive monitoring are also discussed.