Comparison of ultrasonographic measurement of gastric antral volume and pH with or without pharmacological acid aspiration prophylaxis in low-risk surgical patients - A randomized clinical trial.

Background and Aims: The role of preoperative pharmacological prophylaxis in preventing aspiration pneumonitis under general anesthesia (GA) in patients at low risk of aspiration pneumonitis is still under debate. We addressed the need for routine pharmacological aspiration prophylaxis in at-risk population by assessing the change in gastric volume using ultrasound with and without pharmacological acid aspiration prophylaxis. Material and Methods: A single-center, randomized double-blinded trial, with 200 adult patients scheduled for elective surgical procedures under GA, were randomized into a prophylaxis group, in which the patients received oral famotidine and metoclopramide, and a no prophylaxis group, in which the patients did not receive any prophylaxis. Gastric volume derived from preinduction measurement of gastric antral volume by ultrasound, postinduction gastric pH, and incidences of aspiration pneumonitis were compared. Bland-Altman plot was used to determine the level of agreement between measured gastric volume and ultrasonography based on calculated gastric volume. Results: The gastric antral cross-sectional area (CSA) and volume in the no prophylaxis group (3.12 cm2 and 20.11 ml, respectively) were comparable to the prophylaxis group (2.56 cm2 and 19.67 ml, respectively) (P-values 0.97 and 0.63, respectively). Although there was a statistically significant decrease in gastric pH in the no prophylaxis group (P-value 0.01), it was not clinically significant to increase the risk of aspiration pneumonitis based on Roberts and Shirley criteria (P-value 0.39). Conclusion: In an adequately fasted low-risk population, the amount of residual gastric volume was similar and below the aspiration threshold, regardless of the aspiration prophylaxis status.

Shivering and changes in body temperature in patients undergoing caesarean section under spinal anaesthesia with bupivacaine vs bupivacaine and fentanyl: A randomized clinical study.

Background and Aims: Shivering is common after spinal anesthesia in patients undergoing cesarean section. Various drugs have been used for its prevention. The primary aim of this study was to assess the efficacy of adding a small dose of fentanyl intrathecally (12.5 µg) in reducing the occurrence of intraoperative shivering and hypothermia and note any significant side effects in this subset of patients. Material and Methods: In this randomized controlled trial, 148 patients undergoing cesarean section under spinal anesthesia were included. In 74 patients, spinal anesthesia was administered with 1.8 mL of hyperbaric bupivacaine (0.5%), and the remaining 74 patients received 12.5 µg of intrathecal fentanyl with 1.8 mL of hyperbaric bupivacaine. Both were compared to find the incidence of shivering and change in nasopharyngeal and peripheral temperature along with the temperature at the onset of shivering and the grade of shivering. Results: The incidence of shivering was 9.46% in the intrathecal bupivacaine plus fentanyl group, which was significantly less than the group with intrathecal bupivacaine alone (41.89%). The nasopharyngeal and peripheral temperature showed a decreasing trend in both groups but were greater in the plain bupivacaine group. Conclusion: The addition of 12.5 µg of intrathecal fentanyl to bupivacaine in parturient undergoing cesarean section under spinal anesthesia significantly reduces the occurrence and intensity of shivering without its adverse effects such as nausea, vomiting, and pruritus, etc.

Comparison of conventional C-MAC video laryngoscope guided intubation by anesthesia trainees with and without Frova endotracheal introducer: A randomized clinical trial.

BACKGROUND AND AIMS: Successful intubation with video laryngoscopes necessitates good hand-eye coordination and the use of intubation adjuncts like bougie and stylet. We proposed this study to find whether using Frova introducer with C-MAC video laryngoscope will reduce the intubation time in trainee anesthesiologists. MATERIAL AND METHODS: We enrolled 140 adults without any difficult airway predictors. They were randomly assigned to undergo C-MAC video laryngoscope guided intubation by anesthesia residents using tracheal tube preloaded over Frova introducer (n = 70) or without Frova introducer (n = 70). Primary outcome was the intubation time. Secondary outcomes were the number of redirections of tracheal tube or Frova introducer toward glottis, need for external laryngeal maneuvers (ELMs), first attempt intubation success rate, and ease of intubation. RESULTS: The median actual intubation time (IQR) in Frova and non-Frova group, respectively, were 25.46 (28.11-19.80) and 19.96 (26.59-15.52) s (P = 0.001). The number of redirections of TT or Frova introducer toward glottis, first attempt success rate, and ease of intubation were comparable. The need for ELMs [n (%)] was 15 (21.4) and 26 (37.1) in Frova and non-Frova group, respectively (P = 0.04). CONCLUSION: Frova introducer guided endotracheal intubation with C-MAC videolaryngoscope in patients with normal airways had a marginally prolonged intubation time with a significant reduction in the need of external laryngeal manoeuvres but with a comparable number of redirections and attempts. Further research is needed to generalize these findings to patients with difficult airways.

Effect of Acute Vasodilator Testing Using Oxygen in Pulmonary Hypertension Due to Left Heart Disease.

BACKGROUND: Pulmonary vasodilators, including oxygen, have not shown consistent beneficial effects on pulmonary hypertension due to valvular heart disease (PH-VHD). Therefore, the study aimed to assess the effect of 100% fractional inspiration of oxygen (FiO2) on pulmonary and systemic hemodynamics in patients with combined pre- and post-capillary pulmonary hypertension (CpcPH) and isolated post-capillary pulmonary hypertension (IpcPH) due to PH-VHD. METHODS: This prospective study was conducted among patients with PH-VHD undergoing mitral or aortic valve replacement or repair. The study was conducted after induction of anesthesia and pulmonary artery catheterization. Cardiac output was obtained using thermodilution and all direct, and derived hemodynamic variables were obtained at 30% and 100% FiO2. The patients were stratified a priori into responders {(≥10 mmHg fall in mean pulmonary artery pressure (MPAP)} and non-responders. RESULTS: Fifty-seven patients completed the acute vasodilator test. The mean age and body mass index of the study population was 41.8 ± 14.1 years and 21.4 ± 4.6 kg/m2, respectively. There was a significant decrease in MPAP (40.77 ± 12.07 mmHg vs 36.74 ± 13.3 mmHg; P < .001) and pulmonary vascular resistance (PVR) {(median; Interquartile range (IQR); 388; 371 vs 323; 362 dynes sec.cm-5; P < .001) at 100% FiO2. Transpulmonary gradient (TPG) and diastolic pulmonary gradient (DPG) also decreased significantly (P < .001 and P < .001). Cardiac output did not change significantly. The magnitude of decrease in MPAP, PVR, TPG, DPG, and pulmonary artery compliance (PAC) between CpcPH and IpcPH was comparable. Responders did not show a significantly greater fall in MPAP, PVR, TPG, DPG, and PAC after surgery. CONCLUSION: Hyperoxia may lead to reduction in MPAP and PVR in both hemodynamic phenotypes of PH-VHD. A larger sample size is required to support or refute the findings of this study.

Comparison of airway collapsibility following single induction dose ketamine with propofol versus propofol sedation in children undergoing magnetic resonance imaging: A randomised controlled study.

Background and Aims: Adequate sedation is essential for children undergoing magnetic resonance imaging (MRI) console. Propofol is commonly used for sedation, but it has the drawback of upper airway collapse at higher doses, which may be overcome by ketamine. This study was designed to evaluate the beneficial effect of ketamine on propofol in preventing airway collapse. Methods: Fifty-eight children undergoing MRI were randomised to Group P (propofol bolus dose followed by infusion or Group KP (bolus dose of ketamine and propofol followed by propofol infusion). The primary aim is to compare the upper airway cross-sectional area (CSA) and diameters (transverse diameter [TD] and anteroposterior diameter [APD]) obtained from MRI during inspiration and expiration. Results: Upper airway collapse as measured by delta CSA in mean (SD) [95% confidence interval] was statistically more significant between the two groups [at the soft palate level, 16.9 mm2 (19.8) [9.3-24.4] versus 9.0 mm2 (5.50) [6.9-11.1] (P = 0.043); at the base of the tongue level, 15.4 mm2 (11.03) [11.2-19.6] versus 7.48 mm2 (4.83) [5.64-9.32] (P < 0.001); at the epiglottis level, 23.9 (26.05) [14.0-33.8] versus 10.9 mm2 (9.47) [7.35-14.5] (P = 0.014)]. A significant difference was obtained for TD at all levels and for APD at the soft palate and base of tongue level. Conclusion: Adding a single dose of ketamine to propofol reduced the upper airway collapse significantly, as evidenced by the MRI-based measurements of upper airway dimensions, compared to propofol alone.

Role of Acute Normovolemic Hemodilution in Pregnancy for Emergency Cesarean Section in a Patient With Bombay Blood Group.

Postpartum hemorrhage (PPH) is among the leading causes of maternal morbidity and mortality, and various blood conservation strategies can be implemented to minimize blood loss. Acute normovolemic hemodilution (ANH) is a simple yet effective blood management tool in the armamentarium of an anesthesiologist, the use of which can be considered for patients undergoing surgical procedures with inherent bleeding risks, procedures where more than 50% of the patient's circulating blood volume is lost, patients with multiple antibodies and rare blood groups, and those unwilling to undergo an allogenic blood transfusion. We hereby describe the performance of ANH in a pregnant woman with a Bombay blood group during an emergency cesarean section. Existing literature on ANH in obstetric patients does not report adverse fetal or maternal outcomes due to preoperative blood donation and advocates its selected use in situations where the benefits outweigh the risks.

Comparison of retrograde transillumination and conventional technique for flexible videoscopy by novice anaesthesia residents: A randomised controlled trial.

Background and Aims: Retrograde transillumination technique has been found helpful for performing direct and video laryngoscopy by better identification of glottis. The usefulness of this technique during flexible videoscopy by novices has not been evaluated. So, we aimed to compare the retrograde transillumination and conventional technique of flexible videoscopy by novices. The primary outcomes were the time required to visualise the glottis from the point of insertion of the scope into the nostril (T1) and the time needed to see tracheal rings after glottis visualisation (T2). The secondary outcomes were incidence of desaturation with peripheral oxygen saturation (SpO2) <92% and the ease of performance of flexible videoscopy using retrograde transillumination. Methods: A total of 92 surgical patients who are undergoing general anaesthesia with normal airway parameters were randomised into two groups, Group C (Conventional flexible videoscopy- Ambu® aScope™ 3 Broncho Slim) and Group R (Flexible videoscopy aided by retrograde transillumination through the cricothyroid space using an OTICA LED vein finder). Results: The time to visualise glottis from scope insertion into the nose (T1) (median [interquartile range]) in group C and group R was (19.23 [13.6-30.5] versus 22.50 [17.8-25.5] seconds; P value = 0.417) and time to visualise the tracheal rings (T2) was (13.07 [9.1-20.00] versus 12.13 [9.0-19.1] seconds; P value = 0.714) were comparable in both the groups. 61% of residents found the retrograde transillumination to be very helpful. No incidence of desaturation was noted in either group. Conclusion: Retrograde transillumination-aided flexible videoscopy does not shorten the time but facilitates glottis and tracheal rings visualisation among novice anaesthesia residents.

Anesthetic Approach to a Case of Hepatoblastoma With Right Atrial Spread for Simultaneous Resection of Both.

Hepatoblastoma is the most common primary liver tumor in childhood. However, cases involving age >5 years are extremely rare. Invasion of the inferior vena cava and right atrium in hepatoblastoma places the patient in a high-risk group, and due to the rarity of such presentation, the preferred surgical approach is not clear. We present the perioperative anesthetic management of hepatoblastoma in an eight-year-old child with right atrial invasion at diagnosis, with no regression in size of the tumor after chemotherapy, treated subsequently with combined cardiac and liver surgery. Due to the possibility of impingement of the tumor thrombus onto the tricuspid valve or superior vena cava, or systemic embolization from the right atrium, access for the cardiopulmonary bypass was kept ready at the start of surgery. Intraoperative evidence of fragmentation of a small part of the right atrial tumor was noted in trans-esophageal echocardiography midway during left hepatectomy. This necessitated the emergency institution of cardiopulmonary bypass and en-bloc removal of the tumor thrombus with the remaining left hepatectomy specimen. The anesthetic management was further compounded by the risk of peri-operative pulmonary embolization, coagulopathy, blood loss and hemodynamic instability, ischemia-reperfusion injury, and post-operative hepatic, renal and pulmonary complications inherent in hepatectomies. The case presented a unique set of challenges to both surgeons and anesthetists. What was most evident from the successful management of such a case was the need for a team approach, with adequate communication between teams managing the patient.

Airway management in a child with anterior mediastinal mass complicated by cardiac tamponade - Role of spontaneous ventilation.

Induction of general anesthesia in patients with mediastinal mass can lead to life threatening respiratory and cardiovascular complications during induction, maintenance and emergence. The inability of pediatric patient to cooperate for local anesthesia further complicates the management of such cases. Here we report the management of a child with anterior mediastinal mass causing airway compression and massive pericardial effusion posted for right pleuropericardial window.

Intraoperative acute hematuria: Sole clue to mismatch transfusion.

Hemolytic transfusion reactions (HTRs) remain one of the dreaded complications of transfusion-related morbidity and mortality. Here, we describe the diagnosis and management of acute HTR following transfusion of ABO-incompatible packed red blood cell under general anesthesia which manifested solely as acute intraoperative hematuria. A 65-year-old, diabetic male was scheduled for emergency re-explorative laparotomy in view of suspected anastomotic leak following subtotal gastrectomy. One unit of packed cell was transfused intraoperatively. Toward the end of surgery, hematuria was noted by the attending anesthesiologist, and the accidental bladder injury was ruled out by the surgeon. Transfusion of ABO-incompatible blood was spotted; direct Coombs test became positive. To mitigate the impact of incompatible blood, 1 L of 0.9% normal saline was administered. Mannitol 0.5 g/kg and furosemide 20 mg were administered every 8th hourly, and 1 ml/kg/h of urine output was targeted. Sodium bicarbonate (7.5%) 20 meq was administered intravenously to alkalinize the urine.

Spontaneous ventilation as a key ventilation technique during open airway phase in tracheal resection and reconstruction: A case series.

Anaesthetic management of tracheal resection and reconstruction in patients with difficult tracheal pathologies, poses unique challenges-such as pre-operative assessment and preparation, the induction of general anaesthesia, airway sharing with surgeons during the intra-operative period while performing resection and reconstruction, emergence from general anaesthesia, and post-operative care. While there are no guidelines on choosing the ideal airway technique for the intra-operative period, we describe a simple-yet-effective airway modality, viz. spontaneous ventilation, as a key airway technique during the crucial open airway phase during tracheal reconstruction.

Continuous wound infiltration of bupivacaine at two different anatomical planes for caesarean analgesia - A randomised clinical trial.

BACKGROUND AND AIMS: Continuous wound infiltration of local anaesthetics provide postoperative analgesia by peripheral nociceptors blockade.The placement of wound infiltration catheter in the optimal anatomical plane of surgical wound may play a significant role in reducing postoperative pain depends on the surgical procedure. We hypothesised that preperitoneal infusion of local anaesthetics will reduce the postoperative opioid consumption as compared to subcutaneous infusion following cesarean section. METHODS: This was a randomised, double-blinded clinical trial. Fifty-two pregnant women who underwent lower segment caesarean section by Pfannensteil incision, under spinal anaesthesia, were randomised to group 'subcutaneous' and group 'preperitoneal'. A wound infiltration catheter was placed in the subcutaneous or preperitoneal plane, depending on their randomisation at the end of the surgery. Bupivacaine of 0.25% at 5 mL/h was infused for the next 48 h. Pain was assessed using numerical rating scale at 1, 2, 3, 4, 5, 6, 12, 24, 36 and 48 h after surgery. Cumulative postoperative consumption and adverse effects of morphine and complications of the procedure were looked for. RESULTS: Cumulative 48-h morphine consumption showed no statistical significance between the preperitoneal group (15.96 ± 7.69 mg) and subcutaneous group (21.26 ± 11.03 mg); P = 0.058. Pain score was comparable. Independent T-test and Mann-Whitney test were the statistical tests used for continuous and categorical data, respectively. CONCLUSION: Postoperative cumulative morphine consumption and pain scores are comparable when bupivacaine is infused continuously through wound infiltration catheter either in the preperitoneal or subcutaneous layer following Caesarean delivery.

Comparision of Ambu AuraGain™ and LMA® ProSeal in children under controlled ventilation.

BACKGROUND AND AIMS: The LMA ProSeal® is considered a prototype among the second-generation supraglottic airway devices (SAD). The Ambu AuraGain™ is a relatively new, single use, second-generation SAD with a preformed shape. We conducted this study with the aim of comparing the difference in clinical performance between Ambu AuraGain™ and LMA ProSeal® in children receiving controlled ventilation. METHODS: Ninety-four children, aged between 6 months to 12 years, weighing 5 to 30 kg, belonging to American Society of Anesthesiologists Physical Status I and II, undergoing elective surgical procedures, were randomized into two groups. The primary end-point was oropharyngeal seal pressure, and the secondary parameters were the number of attempts, time of insertion, ease of placement of the device and gastric tube, and fiberoptic visualization of the laryngeal aperture. RESULTS: The mean oropharyngeal seal pressure with Ambu AuraGain™ was significantly higher than LMA ProSeal® (23.3 ± 4.6 cmH2O vs 20.6 ± 4.8 cmH2O, P = 0.007, respectively). The ease and success rate for device placement, fiberoptic visualization of the larynx, and complications were comparable. However, the time for insertion in Ambu AuraGain™ group was shorter when compared to LMA ProSeal® group, median (IQR [range]); 12 (10-15) s vs 20 (18-23) s (P < 0.001), respectively. The gastric drain was significantly easier to insert in Ambu AuraGain™ compared to LMA® ProSeal (P = 0.01). CONCLUSION: Our study suggests that Ambu AuraGain™ could be a useful disposable alternative to LMA ProSeal® for securing airway in children.

Perineural vs. intravenous dexmedetomidine as an adjunct to bupivacaine in ultrasound guided fascia iliaca compartment block for femur surgeries: A randomised control trial.

BACKGROUND AND AIMS: Perineural and intravenous dexmedetomidine as a local anaesthetic adjunct has not been compared previously in fascia iliaca compartment block (FICB). The aim of this study was to compare the efficacy and side effect profile of dexmedetomidine as an adjunct to bupivacaine in single dose FICB for femur surgeries in two different routes i.e., perineural and intravenous route. METHODS: Eighty American Society of Anesthesiologists physical status 1, 2 or 3 patients posted for femur surgeries were randomised to receive ultrasound guided FICB. Intravenous group(ID) received 40 mL of 0.25% bupivacaine with 2 mL of 0.9% saline for FICB along with 1 µg/kg dexmedetomidine intravenous infusion over 30 min as loading dose followed by 0.5 µg/kg/h as maintenance dose till the end of surgery. Perineural group (LD) received 40 mL of 0.25% bupivacaine with 2 mL of 1 µg/kg dexmedetomidine for FICB. M ean duration of postoperative analgesia and 24 h postoperative morphine consumption as primary and secondary outcome respectively, has been compared. RESULTS: The duration of postoperative analgesia was 8 h 36 min ± 1 h 36 min and 10 h 42 min ± 1 h 36 min for the ID and LD groups, respectively (P = 0.001). A 24 h postoperative morphine consumption in Group ID was 19.7 ± 1.9 mg compared to 17.5 ± 2.2 mg in LD groups (P = 0.001). CONCLUSION: Perineural dexmedetomidine effectively prolongs the USG guided FICB analgesic duration and reduces the 24 h postoperative morphine consumption when compared to intravenous dexmedetomidine as a local anaesthetic adjuvant for femur surgeries.

Changes in Gas Composition during Low Flow Anaesthesia without Nitrous Oxide.

INTRODUCTION: Low flow anaesthesia utilising Oxygen (O2) and Nitrous Oxide (N2O) mixture carries a risk of hypoxia, but avoiding N2O results in increased analgesic and volatile anaesthetic agent requirement. AIM: This study attempted to find the lowest Fraction of inspired Oxygen (FiO2) levels achieved with a mixture of 300 mL/min each of O2 and medical air over two hours and to compare the overall analgesic requirement and cost while using similar flows of N2O and O2, respectively. MATERIALS AND METHODS: A prospective observational study was conducted between March 2015 and June 2016 at the Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. Patients of American Society of Anaesthesiologists (ASA) Grade 1 and 2 undergoing surgery under general anaesthesia with an endotracheal tube were included in the study, in two groups of 40 each. In the initial ten minutes following induction of anaesthesia, both groups received high Fresh Gas Flows (FGF) of 3 L/min each (Group O: medical air and oxygen; Group N: N2O and oxygen), following which the FGF rates were reduced to 300 ml/min each. Any value of FiO2 lesser than 0.3 during the duration of anaesthesia was considered to render the technique unsafe for clinical use. SPSS software version 20.0 was used to generate data and figures. RESULTS: The lowest FiO2 recorded was 0.33 in Group O and 0.3 in Group N which occurred at the end of two hours. Mean analgesic requirement was significantly higher in Group O compared to Group N (151.85 µg, 124.85 µg; p-value=0.004) with a 62% increase in the cost incurred. CONCLUSION: The use of medical air and oxygen in flows of 300 ml/min each following initial high flows of 3 L/min appears to be a safe technique. However, this combination was associated with an increase in the cost of anaesthesia and in the need for additional intra-operative analgesia.