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BACKGROUND AND AIMS: Caudal analgesia is a good, reliable, and easy method to provide intraoperative and postoperative analgesia for infra-umbilical surgeries in children. Many additives are being used in combination with local anesthetics in caudal block to prolong the postoperative analgesia (clonidine, midazolam, ketamine, fentanyl, and dexmedetomidine). The purpose of this study was to compare the intraoperative hemodynamics, postoperative analgesia, postoperative rescue analgesic requirement, postoperative sedation and side-effects of clonidine and midazolam used as adjuvants to bupivacaine for caudal analgesia. MATERIAL AND METHODS: Following approval from Institutional Ethical Research Committee, 75 American Society of Anesthesiologists I and II patients aged between 1 and 7 years undergoing various elective infra-umbilical surgical procedures were included in this study. The patients were randomly allocated into three groups of 25 patients each. Group B received 1 ml/kg 0.25% bupivacaine in normal saline, Group BC received 1 ml/kg 0.25% bupivacaine + 1 µg/kg clonidine in normal saline, and Group BM received 1ml/kg 0.25% bupivacaine + 30 µg/kg midazolam in normal saline. The various parameters studied were intraoperative hemodynamic changes, duration of postoperative analgesia, postoperative sedation, postoperative analgesic requirement, and incidence of side-effects. RESULTS: All the groups were similar with respect to patient and block characteristics. The hemodynamic parameters before and after administering caudal analgesia were also comparable. The mean duration of analgesia was 724.80 ± 60.29 min in Group BC, 605.40 ± 82.37 min in Group BM and 295.00 ± 41.78 min in Group B. Thus, the duration of analgesia was significantly prolonged in Group BC compared to Groups BM and B. The FLACC pain score was higher in Group B at the end of 4th, 8th and 12th h compared with Group BC and Group BM. Furthermore at the end of 12th h, pain scores were significantly higher in Group BM compared to Group BC. Only 1 child in Group BC received three rescue medications compared to 15 (60%) children in Group B and 7 (28%) children in Group BM. None of the groups were treated for bradycardia or hypotension and no significant sedation was noted. CONCLUSION: This study showed that the addition of both clonidine (1 µg/kg) and midazolam (30 µg/kg) with bupivacaine administered caudally significantly increase the duration of postoperative analgesia with minimal side-effects in children. The use of clonidine as an additive to bupivacaine in caudal epidural is a superior choice to midazolam as it reduces the demand of postoperative rescue analgesics significantly.
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BACKGROUND: Gastric calibration tubes (GCTs) are a unique component of bariatric surgery. This study aimed to assess changes in the endotracheal tube (ETT) cuff pressure during laparoscopic bariatric surgery. METHODS: This was a prospective observational study consisting of 124 American Society of Anesthesiologists class I-III morbidly obese patients (body mass index > 40 kg/m2 ) undergoing elective laparoscopic bariatric surgery under general anesthesia. The baseline ETT cuff pressure was 28 cmH2O. Cuff pressure, peak airway pressure, and hemodynamic changes were observed during various steps of bariatric surgery. Immediate postoperative complications during the first 24 h were recorded. RESULTS: ETT cuff pressure increased significantly from the baseline (28 cmH2O) after insertion of GCT (36.3 ± 7.3 cmH2O) and creation of carboperitoneum (33.3 ± 3.8 cmH2O). Cuff pressure decreased significantly on GCT removal (24.0 ± 3.0 cmH2O) and release of carboperitoneum (24.7 ± 3.0 cmH2O). Peak airway pressure increased from the initial baseline value of 25.1 ± 3.7 to 26.5 ± 4.5 after GCT insertion, creation of carboperitoneum (32.6 ± 4.4), attainment of reverse Trendelenburg position (32.3 ± 4.0), and subsequent return to supine position 32.5 ± 4.8. CONCLUSIONS: The endotracheal cuff pressure significantly varies during the intraoperative period. Routine monitoring and readjustment of cuff pressure are advisable in all laparoscopic bariatric surgeries to minimize the possibility of postoperative complications.
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BACKGROUND AND AIMS: Effects of fluid absorption on hematological profile in the immediate postoperative period in patients undergoing percutaneous nephrolithotomy (PCNL) have not been given due importance. Considering the limited number of studies available, we conducted this study to evaluate the changes in hemodynamics, complete blood count (CBC), and electrolytes in patients undergoing PCNL using normal saline for irrigation in the prone position. Furthermore, we evaluated the common factors known to affect the absorption. MATERIALS AND METHODS: Forty American Society of Anesthesiologist Class I or II patients aged 18-65 years were recruited who underwent PCNL under general anesthesia. Heart rate, blood pressure (BP), CBC, and serum electrolytes were recorded preoperatively and just before extubation and compared using the Student's t-test. Correlation of these changes with height and total volume of irrigating fluid, total time of irrigation, duration of operation, and total intravenous fluids administered intraoperatively were performed using the Pearson's correlation coefficient. RESULTS: There was a statistically significant fall in mean hemoglobin (12.5 g/dL to 11.5 g/dL), packed cell volume (38.6%-35.6%), platelet count (2.9 × 105 cells/µL to 2.5 × 105 cells/µL), and sodium ion concentration (Na+) (138.9 meq/L to 137.7 meq/L) in the immediate postoperative period as compared to that of the preoperative values. Rest of the blood indices and electrolytes did not show any significant change. There was a significant rise in postoperative heart rate and BP. Postoperative systolic BP showed a significant positive correlation with the total volume of irrigating fluid. No significant correlation was observed with height and total time of irrigation. CONCLUSION: This study reveals that there is a significant fall in hemoglobin and Na+ during PCNL in the immediate postoperative period. Only, total volume of irrigating fluid and total duration of surgery had a significant correlation with blood cell indices.
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BACKGROUND AND AIMS: Oocyte retrieval is the only vital aspect of in vitro fertilization requiring anesthesia. Previous studies have shown the inconclusive role of paracervical block (PCB) in transvaginal oocyte retrieval (TVOR) under ultrasound guidance. This study was planned to observe the role and efficacy of PCB as measured by the amount of propofol used as rescue in patients undergoing TVOR and grading it on the basis of body mass index (BMI). METHODS: This prospective, comparative study, conducted over 1 year, recruited 140 American Society of Anesthesiologists I and II patients and divided into two groups as follows: Group A received PCB with 20 ml of 1% lignocaine and Group B received no PCB. Total propofol consumed, BMI, time taken, oocytes retrieved, postprocedure visual analog scale score, and complications were noted. In both the groups, patients were then divided into underweight, normal, overweight, and obese according to BMI. Statistical analysis was done using Statistical Package Mini Tab Version 17.0. The primary objective was to study the efficacy of PCB as estimated by amount of propofol required during the procedure. The secondary aim was to assess the effect of BMI on the efficacy of PCB. RESULTS: Propofol requirement was found to be significantly more (P < 0.05) in Group B patients (172.14 ± 64.15) in comparison to Group A (132.14 ± 66.11). Amount of propofol required in normal BMI and overweight patients was significantly higher in Group B. No significant difference was observed in underweight, and obese patients in both the groups. CONCLUSION: PCB reduces the consumption of propofol in normal BMI patients. Underweight and obese population do not benefit from PCB.
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BACKGROUND: The effect of positive end-expiratory pressure (PEEP) has been studied in detail after induction of general anesthesia especially in obese individuals. However, sparse information can be gathered from the literature regarding its effect when applied at the time of induction and the time of onset of its effect. Thus, this study was planned to assess the effect of PEEP when applied for a single minute in morbidly obese patients. MATERIALS AND METHODS: This was a randomized prospective study comprising seven morbidly obese patients (body mass index ≥40 kg/m2). Control group included 30 patients who received no PEEP at the time of induction. The study group consisted of thirty patients who were given a PEEP of 10 cmH2O. Serial arterial blood gas samples were taken preoperatively, at the time of intubation, 5 min after intubation and 10 min after intubation. RESULTS: PaO2 was significantly higher in test group (242.0 ± 116.0 mmHg) than in control group (183.0 ± 107.0 mmHg) just after intubation. PaCO2 was comparable in control group (43.73 ± 6.32 mmHg) and test group (44.52 ± 6.33 mmHg) just after intubation but was significantly less in test group than in control group at 5 and 10 min thereafter. Hemodynamic parameters were comparable in both groups at all time intervals. CONCLUSION: Application of even a single minute of PEEP at the time of induction improves oxygenation without any adverse effects on hemodynamics, in morbidly obese patients undergoing laparoscopic Bariatric surgery.
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BACKGROUND: Positive end-expiratory pressure (PEEP) at the time of induction increases oxygenation by preventing lung atelectasis. However, PEEP may not prove beneficial in all cases. Factors affecting the action of PEEP have not been elucidated well and remain controversial. Pulmonary vasculature has direct bearing on the action of PEEP as has been proven in the previous studies. Thus, this prospective study was planned to evaluate the action of PEEP on the basis of pulmonary artery systolic pressure (PASP) which is noninvasive and easily measured by transthoracic echocardiography. MATERIALS AND METHODS: Seventy morbidly obese patients, the American Society of Anesthesiologists Grade II, or III, aged 20-65 years with body mass index >40 kg/m2, scheduled for elective laparoscopic bariatric surgery were included. Patients who denied consent, those undergoing emergency and/or open surgery and those requiring >2 attempts for intubation were excluded from the study. Ten patients had to be excluded. Thus, a total of sixty patients participated in the study. Thirty patients received no PEEP at the time of induction while other thirty patients were given a PEEP of 10 cm of H2O. Serial ABG samples were taken preoperatively, at the time of intubation, 5 min after intubation, and 10 min after intubation. Patients were then divided into four groups on the basis of PASP value of ≤30 mm Hg with and without PEEP or >30 mm Hg with and without PEEP. PRIMARY OUTCOME: The primary outcome was the effect of PEEP of 10 cm of H2 O on ABG and hemodynamics in morbidly obese patients. SECONDARY OUTCOME: The secondary outcome was the effect of PASP on the action of PEEP in morbidly obese patients undergoing laparoscopic surgery. RESULTS: Patients having PASP of >30 mm Hg had significant improvement in oxygenation on PEEP application (270.11 ± 119.26 mm Hg) as compared to those without PEEP (157.57 ± 109.29 mm Hg) just after intubation. The increase in oxygenation remained significant at all time intervals. Patients with PASP ≤30 mm Hg did not show significant improvement in oxygenation with PEEP application (177.09 ± 85.85 mm Hg as compared to 226.27 ± 92.42 mm Hg without PEEP). Hemodynamic parameters did not show statistically significant alterations. CONCLUSION: Morbidly obese patients who have PASP >30 mm Hg benefit most from the PEEP. Thus, PASP which is an easily measurable noninvasive parameter can be used as a criterion for selecting patients who benefit from PEEP application.
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BACKGROUND: Ketamine, in low doses, is known to possess intense analgesic properties. The available literature shows wide variation regarding the time and dose of administration of ketamine during surgery. AIM: The aim of this study was to evaluate the effect of intraoperative administration of ketamine when used as sole analgesic in low doses, on hemodynamics and postoperative analgesia in patients undergoing laparoscopic gynecological surgery and compared on the basis of duration of surgery. SETTINGS AND DESIGN: This prospective, observational study was conducted from July to December 2015, over a period of 6 months in a tertiary care medical college and hospital. MATERIALS AND METHODS: Seventy patients between 23 and 55 years planned for laparoscopic gynecological surgery were recruited. Ketamine was given in a dose of 0.5 mg/kg preoperatively and then repeated every ½ hourly in a dose of 0.25 mg/kg throughout the surgery. Hemodynamic parameters, time to the first rescue analgesia and complications were recorded for the first 8 h. Statistical evaluation was done and result expressed as percentage. Paired t-test was employed for the comparison of numerical variables within the group. RESULTS: Seventy percent of the patients did not require any postoperative rescue analgesia during the first 8 h after surgery. None of the patients complained of pain immediately after extubation, and 16% of the patients had minor postoperative complications. The intraoperative hemodynamic profile was significantly altered. Duration of surgery and dose of ketamine required did not affect the duration of analgesia. CONCLUSION: Ketamine in low dose proved to be an efficacious analgesic even in the long duration laparoscopic gynecological surgeries. It stabilizes intraoperative hemodynamics thereby reducing the requirement of other anesthetic and antihypertensive agents.
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A 7-year-old girl had presented with right cheek swelling noted 3 months earlier. It was slowly progressive. Swelling was well defined, non-tender, smooth, firm in consistency and measured 4×4 cm. Intraoral examination revealed no missing teeth. Permanent teeth - central incisors (upper and lower), primary lateral incisor, canine and first and second molar were present. X-ray paranasal sinuses showed well-defined unilocular radiolucency with a thin sclerotic border enclosing permanent first molar, premolar and canine on the right side and first molar on the left side. The cyst was removed by enucleation procedure. Mucoperiosteal flap was elevated, and paper thin bone overlying the cyst was removed. The cyst was enclosing the permanent canine, premolar and molar teeth. Histopathological report was consistent with the dentigerous cyst. After 1-year follow-up, the patient has no obvious swelling over the cheek.