Prophylactic norepinephrine infusion or leg wrapping for postspinal hypotension in elective caesarean delivery: A randomised, double-blind, placebo-controlled trial.

BACKGROUND: Because of its alpha and beta agonist properties, norepinephrine infusion is currently being studied for the prevention of spinal hypotension during caesarean delivery. Vasopressor infusions are not always possible if there is an unavailability of infusion pumps. Leg wrapping with crepe bandage is an effective technique for prevention of postspinal hypotension and could be useful in resource-poor settings. OBJECTIVE: The aim of this study was to compare the incidence of hypotension with norepinephrine infusion or leg wrapping with a control group in women undergoing caesarean delivery with spinal anaesthesia. DESIGN: Randomised, double-blind, controlled trial. SETTING: Single centre, tertiary level institute, India.Study period 3 April 2018 to 31 March 2019. PATIENTS: One hundred and forty-four women aged 19 to 40 years with a singleton pregnancy. INTERVENTION: In group Leg Wrapping, crepe bandage was applied tightly from metatarsus to groin. Group Norepinephrine and the control group received sham leg wrapping. In group Norepinephrine, the women received a norepinephrine infusion according to their body weight, while group Leg Wrapping and the control group received a 0.9% normal saline infusion at a similar rate. All three groups received a 500 ml co-load of Ringer's solution over 15 min. Noninvasive SBP was monitored every 2 min until delivery, and every 5 min thereafter. Any hypotensive event (SBP < 20% of baseline) was treated with an intravenous bolus of norepinephrine (7.5 µg). MAIN OUTCOME MEASURES: The primary outcome was the incidence of hypotension. The secondary outcomes were performance error measurements, and the incidences of hypertension, bradycardia, norepinephrine rescue bolus and neonatal outcomes. RESULTS: The incidences of hypotension were significantly lower in the norepinephrine infusion group and the leg wrapping groups than the control group (P values 0.021 for both). Performance error calculations showed that SBP was maintained closer to baseline with the norepinephrine infusion. CONCLUSION: Norepinephrine infusion and leg wrapping can both reduce the incidence of postspinal hypotension during elective caesarean delivery compared with saline infusion alone. TRIAL REGISTRATION: Clinical trial number and registry URL: CTRI/2018/04/012917 registered at Clinical Trial Registry of India http://www.ctri.nic.in/Clinicaltrials/login.php.

Comparison of recovery characteristics with two different washout techniques of desflurane anaesthesia: A randomised controlled trial.

BACKGROUND: Rapid emergence with low soluble inhalational agents (IA) is offset by a significant association with emergence agitation (EA). Research on the influence of elimination methods of IA on recovery characteristics is very few. We conducted this study to compare the recovery characteristics of slow elimination (SE) of desflurane with purging technique. METHODOLOGY: Forty-five participants, 18-60 years, undergoing elective laparoscopic surgeries were randomised either into Group-P (n = 23) or Group-SE (n = 22). A standardised induction-maintenance protocol including desflurane and fresh gas flow (FGF) of 0.8 l/min was followed. During recovery, the FGF was increased in Group-P to 10 L/min and in Group-SE it was continued at 0.8 L/min. The decrement in end-tidal concentration of desflurane, time for emergence and extubation, EA and time for psychomotor recovery were noted. RESULTS: Time for emergence (Group-SE: 22.8 ± 9 vs. Group-P: 5.6 ± 1.5 min; P = 0.000) and emergence to extubation duration (Group-SE: 128 ± 36 s vs. Group-P: 11.5 ± 1.7 s; P = 0.000) were longer in the Group-SE than in Group-P. EA occurred in 22.7% patients in Group-SE and in 4.3% patients in Group-P (P = 0.07). Psychomotor recovery to baseline values was seen in more number of patients in Group-SE than Group-P at 30 min. There was no difference between the groups at 60 min post-extubation. CONCLUSIONS: Slow elimination using FGF of 0.8 L/min significantly prolongs emergence even with low soluble agent like desflurane. SE is not beneficial in decreasing the incidence of EA or hastening psychomotor recovery. Purging technique is, therefore, a better-suited technique with fewer complications for eliminating desflurane.

Arm position and collapsibility of infraclavicular axillary vein during voluntary breathing: An ultrasound-guided observational study.

BACKGROUND: Arm abduction influences cross-sectional area of the infraclavicular axillary vein, yet the effect of arm abduction on collapsibility of the vein has not been quantified. Decrease in collapsibility of the axillary vein can enable successful cannulation and can decrease injury to underlying vital structures. METHODS: The infraclavicular axillary vein was scanned in 70 patients close to the clavicle with a high-frequency linear transducer in arm adducted position (Point A), after arm abduction at the initial probe position (Point A') and after tracing the vein medially close to clavicle (Point B). Maximum and minimum cross-sectional area and circumference during tidal breathing and collapsibility indices during tidal and deep breathing were measured at three probe positions. RESULTS: The percentage change with respiration in cross-sectional area, circumference and the collapsibility indices computed from the above measurements were lesser in arm abducted position (p < 0.001). There was decrease in collapsibility index during tidal breathing from 25 at Point A to 7 at Point A' and 3 at Point B. Collapsibility index reduced from 91 at Point A to 30 at Point A' and 35 at Point B during deep breathing. CONCLUSION: We conclude that the collapsibility of the infraclavicular axillary vein could be reduced by arm abduction, and hence, abduction could be proposed as the ideal arm position for ultrasound-guided infraclavicular axillary vein cannulation.

Sonographic visualization and cannulation of the axillary vein in two arm positions during mechanical ventilation: A randomized trial.

BACKGROUND: Abduction of the arm has been used for ultrasound-guided infraclavicular axillary vein cannulation. We evaluated the influence of arm position on sonographic visualization and cannulation of the axillary vein in patients receiving mechanical ventilation. METHODS: Sixty patients scheduled to undergo surgery under general anaesthesia with controlled mechanical ventilation were included in this prospective randomized study. The depth, size and distance of axillary vein to the pleura were recorded at three points: Point A, the most proximal part of the axillary vein visualized with adduction; Point A', Point A in abduction; and Point B, the most proximal part of axillary vein visualized in abduction. Cephalic movement of the clavicle at Point A' and the distance between Point A and Point B were noted. In Group A, cannulation was performed at Point A in the adducted arm and at Point B with the abducted arm in Group B after randomization. RESULTS: Abduction moved the clavicle cephalad by 2.2 ± 0.6 cm and increased sonographic visualization of the axillary vein by 2.2 ± 0.5 cm in length, when compared with adduction. The distance from the vein to pleura was higher in Point A' (p < 0.001). No differences were found during cannulation in terms of first-pass success rate or number of attempts. CONCLUSION: Abducted position moved the clavicle cephalad and allowed sonographic visualization of infraclavicular axillary vein approximately 2 cm more proximally than with the adducted arm, with a comparable rate of cannulation success.

Subarachnoid block with continuous TAP catheter analgesia produces less chronic pain and better functional outcome after inguinal hernioplasty: a randomized controlled observer-blinded study.

BACKGROUND AND OBJECTIVES: The major concern after inguinal hernioplasty is chronic postsurgical pain and impaired quality of life due to central sensitization. Preoperative, intraoperative, and postoperative pre-emptive analgesia using regional techniques may help prevent the development of central sensitization. This study evaluated the effect of regional anesthesia followed by continuous regional analgesia on postoperative pain and functional outcome following inguinal hernioplasty. METHODS: Seventy-two consecutive patients scheduled to undergo open mesh inguinal hernioplasty were randomly allocated to one of three groups: subarachnoid block alone (group SAB), general anesthesia alone (group GA), or subarachnoid block combined with a continuous transverse abdominis plane block (group TAP). Pain and functional outcome was assessed before and 6 months following the surgery using the Core Outcome Measures Index score adapted for patients with hernia (COMI-hernia). During the first 72 hours postoperatively, pain was assessed at rest and during five different activities using the numerical rating scale. RESULTS: Six months following the surgery, the COMI-hernia score was lower in group TAP than in group GA or group SAB (0.54±0.41 vs 0.88±0.43 and 1.00±0.54, respectively; p<0.02). Pain at rest (p<0.02) and during activities (p<0.001) was lowest in group TAP during the first 72 hours postoperatively. CONCLUSIONS: A subarachnoid block combined with continuous postoperative analgesia via a transverse abdominis plane catheter provided better pain control and functional outcome 6 months following inguinal hernioplasty as well as better postoperative analgesia. CLINICAL TRIAL REGISTRATION: CTRI/2016/09/007238.