Tranexamic Acid Is Associated With Improved Operative Field in Orthognathic Surgery.

PURPOSE: In the past, both tranexamic acid and dexmedetomidine have been used separately to decrease intraoperative blood loss during orthognathic surgery. However, their combined use in the same setting has never been prospectively evaluated. The present study was conducted to evaluate the effect of tranexamic acid on operative field visibility and blood loss during orthognathic surgery after dexmedetomidine-induced hypotensive anesthesia. PATIENTS AND METHODS: The present prospective, randomized clinical trial included patients who had undergone orthognathic surgery under general anesthesia. The patients were divided into 2 groups. The dexmedetomidine and tranexamic (DT) group received an intravenous bolus of tranexamic acid (15 mg/kg) and intravenous dexmedetomidine (0.25 to 0.7 µg/kg/hr) as maintenance infusion. The dexmedetomidine (DS) group received only intravenous dexmedetomidine at the same dosage. All the patients received a bolus dose of intravenous dexmedetomidine (1 µg/kg) before the start of anesthesia induction. The operating surgeon rated the quality of the surgical visual field every 15 minutes using the Fromme ordinal scale. Intraoperative blood loss was estimated using the modified gross formula. The operating surgeon's satisfaction was assessed using a Likert scale. Data were analyzed using SPSS, version 22.0 (IBM Corp, Armonk, NY). Kolmogorov-Smirnov tests were used to assess the normality of the measured data, and categorical variables were analyzed using the χ2 or Fischer exact test. RESULTS: The study sample included 36 patients, with a mean age of 23.67 ± 11.298 years in the DS group and 20.28 ± 3.286 years in the DT group. Of the patients in the DS and DT groups, 66.66 and 61.11% were male, respectively. No statistically significant differences were found in the baseline characteristics between the 2 treatment groups. The surgeon reported a significantly better surgical visual field in the DT group compared with that in the DS group (P = .001). Also, the intraoperative blood loss significantly less in the DT group (231.11 ± 137.64 mL vs 360.17 ± 187.86 mL; P = .025). CONCLUSIONS: Tranexamic acid improved surgical field visibility and reduced intraoperative blood loss when administered in conjunction with dexmedetomidine during orthognathic surgery under controlled hypotensive anesthesia.

Ultrasound guided superior laryngeal nerve block as an adjuvant to generalanesthesia during endoscopic laryngeal surgery: A prospective, randomized, double-blind trial.

INTRODUCTION: Blindly administered bilateral (B/L) superior laryngeal nerve (SLN) blocks, have been used to decrease the perioperative stress response of endoscopic laryngosurgeries. Use of ultrasound (USG) for giving these blocks is more likely to be successful, with fewer complications. We evaluated the efficacy of USG guided B/L SLN block in decreasing perioperative cough, sore-throat and hoarseness of voice. MATERIAL AND METHODS: This study was conducted on forty patients undergoing endoscopic laryngosurgery under GA. Patients were randomized into two groups of 20 patients each. Patients in group C received GA, whereas those in group L received USG-guided SLN block bilaterally with 2.5 ml of 2% lignocaine, along with GA. Postoperative cough, sore throat and hoarseness of voice was measured at 30 min, 2 h, 4 h and 24 h following transfer to post-anesthesia care unit. RESULTS: Patients receiving SLN block had significantly lower incidence of perioperative cough (20% in group L vs 90% in group C; p value - 0.0001) as well as sore throat (5% in group L vs 95% in group C; p value - 0.0001). In these patients, severity of hoarseness of voice was greater in the early postoperative period (100% in group L vs 70% in group C; p value - 0.027), while it decreased significantly at 24 h postoperatively(0.0% in group L vs 30% in group C; p value - 0.027). CONCLUSION: USG guided SLN block as an adjuvant to GA resulted in better recovery profile of the patients with significant reduction in postoperative cough, sore throat and hoarseness of voice.

Comparison of intubation conditions with CMAC Miller videolaryngoscope and conventional Miller laryngoscope in lateral position in infants: A prospective randomized trial.

BACKGROUND: Endotracheal intubation in lateral position in infants is a challenge. This difficulty may be surmounted to some extent by using videolaryngoscopes but the routine use of these devices as a tool to secure the airway in lateral position remains unevaluated. Therefore, we conducted a prospective, randomized controlled trial to compare the intubation conditions achieved with the CMAC videolaryngoscope and the Miller Laryngoscope in lateral position in infants. We hypothesized that CMAC videolaryngoscope would provide a better laryngoscopic view and reduce the time to intubation compared to the Miller blade. METHODS: Sixty-four children aged <1 year, belonging to American Society of Anesthesiologists physical status I-III requiring endotracheal intubation were randomized to undergo tracheal intubation with either the Miller laryngoscope (n = 32) or the CMAC videolaryngoscope (n = 32) in left lateral position. Anesthesia was induced with sevoflurane or thiopentone 5-8 mg/kg IV and atracurium 0.5 mg/kg IV. Total time taken to intubate was assessed as the primary outcome. Laryngoscopic view, intubation difficulty score, success rate of tracheal intubation, number of attempts, maneuvers used, and any airway complications were recorded as secondary outcomes. RESULTS: The difference in the mean time to intubate (95% confidence interval) between the Miller and CMAC group was 6.1 (1.7-10.4) seconds. Furthermore, the CMAC videolaryngoscope provided a better laryngoscopic view compared to the conventional Miller blade. In addition, the Intubation Difficulty Scale score was less in the CMAC videolaryngoscope group. CONCLUSION: The CMAC videolaryngoscope decreases the time taken to intubate and reduces the intubation difficulty when compared to the Miller laryngoscope. Therefore, the CMAC videolaryngoscope may be more useful device when intubating the trachea of infants in the lateral position.

Comparison of quality of the surgical field after controlled hypotension using esmolol and magnesium sulfate during endoscopic sinus surgery.

BACKGROUND AND AIMS: Most vital aspect of Endoscopic Sinus Surgery (ESS) is an optimal visibility in the surgical field. This invariably requires controlled hypotension to facilitate surgical dissection and to decrease operative time. We used esmolol and magnesium sulfate to achieve controlled hypotension and assessed the quality of the surgical field in ESS. MATERIAL AND METHODS: A total of 30 patients undergoing ESS, were enrolled in three parallel groups of 10 patients each in a prospective randomized double-blind study. "Magnesium Sulfate group" received magnesium sulfate 40 mg/kg intravenously (i.v.) as a bolus over 10 min before induction of anesthesia, followed by 15-30 mg/kg/h through infusion. "Esmolol group" received 0.5 mg/kg i.v. bolus over 10 min after induction followed by 150-300 µg/kg/min infusion and "control group" received normal saline in same volume schedule. The primary aim was to assess the quality of surgical field, using Fromme scale. Category Scale values of all the three groups were compared using Kruskal-Wallis analysis of variance (ANOVA) test. Hemodynamic data was compared using ANOVA test. RESULTS: Quality of the surgical field was better in both magnesium sulfate and esmolol groups as compared to the control group. Durations of anesthesia and surgery were significantly lower in esmolol group as compared to the control group. Blood loss was comparable in all the three groups. CONCLUSION: Quality of the surgical field was better in esmolol and magnesium sulfate groups as compared to control group. Duration of surgery was significantly less in esmolol group as compared to other two groups.

Truview EVO2 Laryngoscope Reduces Intubation Difficulty in Maxillofacial Surgeries.

PURPOSE: Recently, there has been a dramatic increase in the use of the Truview EVO2 for the management of patients with potentially difficult airways. However, the comparison of Truview EVO2 with the classic Macintosh laryngoscope in patients with maxillofacial trauma remains unevaluated. Thus, the purpose of this study was to evaluate and compare the intubation conditions with the Truview EVO2 video laryngoscope and the Macintosh laryngoscope in patients with maxillofacial injury. MATERIALS AND METHODS: Forty-two patients with American Society of Anesthesiologists status I and II requiring nasotracheal intubation for maxillofacial surgery were included in this prospective randomized trial. Anesthesia was induced with fentanyl 2 µg/kg, propofol 2 to 3 mg/kg, and rocuronium bromide 0.6 mg/kg. Intubation was performed with the Macintosh laryngoscope or the Truview EVO2 video laryngoscope. Comparative data based on the Intubation Difficulty Scale score were assessed as the primary outcome. Laryngoscopic view, time taken for glottis visualization, time taken to pass the endotracheal tube, total time to intubate, and the number of optimizing and hemodynamic variables were recorded as secondary outcomes. RESULTS: The 2 groups were comparable in patient characteristics and preoperative airway assessment parameters. The Intubation Difficulty Scale score was significantly less in the Truview EVO2 group compared with the Macintosh group (mean ± standard deviation, 0.30 ± 0.7 vs 1.70 ± 1.8; P = .002). The Truview EVO2 video laryngoscope required significantly less time for glottic visualization (9.40 ± 10.9; P = .002). The Truview EVO2 provided a significantly better laryngoscopic view as graded by the percentage of glottic opening and the modified Cormack-Lehane grading system compared with the Macintosh laryngoscope (P < .002). The hemodynamic variables, number of optimizing maneuvers, and the incidence of side-effects were comparable in the 2 groups. CONCLUSION: The Truview EVO2 performs better than the Macintosh laryngoscope because it considerably decreases the intubation difficulty in patients undergoing maxillofacial surgeries. Therefore, the Truview EVO2 could be a good alternative for managing a difficult airway in patients with maxillofacial injury.

Pyeloplasty for hydronephrosis: Issues of double J stent versus nephrostomy tube as drainage technique.

AIMS: To compare the efficacy, complications, cost analysis and hospital stay between two methods of drainage of the kidney: double J (DJ) stent versus nephrostomy tube following open pyeloplasty for ureteropelvic junction obstruction hydronephrosis. PATIENTS AND METHODS: This was a prospective randomized study of 20 patients in each group over 14 months. Pre and post-operative (3 months) function and drainage were assessed by ethylenedicysteine scan and intravenous urogram. RESULTS: Both groups showed similar good improvement in function and drainage. Nephrostomy group had significantly longer hospital stay (P < 0.001) but incurred less cost. Complications with nephrostomy included tube breakage (n = 1) and urine leak after tube removal (n = 2). DJ stents were associated with stent migration (n = 4), increased frequency of micturition (n = 9), dysuria (n = 4) and urinary tract infection (n = 1). CONCLUSION: Both methods of drainage did not interfere with improvement after pyeloplasty. Minor complications were more with DJ stent (P = 0.0003). Although overall cost of treatment was more with stents, they reduced length of hospital stay. Optimal length of stent is essential to reduce complications secondary to migration and bladder irritation.

Laparoscopic nephrectomy in children for benign conditions: indications and outcome.

AIM: To analyze the indications and outcome of laparoscopic nephrectomy for benign non-functioning kidneys in children. MATERIALS AND METHODS: The data of all patients operated over a 10 year period was retrospectively analyzed. RESULTS: There were 56 children, aged 4 months to 12 years with a male: female ratio of 2.3:1. The most common presentation in boys and girls was urinary tract infection (UTI) (61.5% and 47.05% respectively). Incontinence due to ectopic ureter was a close second in girls (41.17%). The most common underlying conditions were vesico-ureteric reflux (42.85%) and multicystic dysplastic kidney (23.2%). There were 6 nephrectomies, 4 heminephroureterectomies and the remaining nephroureterectomies. All children tolerated the surgery well. One patient underwent a concomitant cholecystectomy. The post-operative problems encountered were UTI (1), urine retention (1), pyonephrosis in the opposite kidney and development of contra-lateral reflux (1). All others had resolution of pre-operative symptoms with good cosmesis. CONCLUSIONS: As per available literature, this appears to be the largest Indian series of pediatric laparoscopic nephrectomies for benign non-functioning kidneys. Laparoscopic approach gives excellent results provided pre-operative investigations rule out other causes for the symptoms with which the patient presents. Often it is not the kidney but the dilated dysplastic ureter which is the seat of stasis and infection or pain and therefore should be completely removed.

Olanzapine versus standard antiemetic prophylaxis for the prevention of post-discharge nausea and vomiting after propofol-based general anaesthesia: A randomised controlled trial.

Background and Aims: Post-discharge nausea and vomiting (PDNV) is a pertinent problem in patients undergoing ambulatory surgery. The objective of this study was to assess the efficacy of the novel drug olanzapine, which has proved its efficiency in patients undergoing highly emetogenic chemotherapy for PDNV prevention. Methods: This randomised controlled trial recruited 106 adult patients (18-65 years) undergoing highly emetogenic daycare surgeries with propofol-based general anaesthesia (GA). Group O received preoperative oral olanzapine 10 mg, and Group C, acting as a control, received 8 mg of intravenous dexamethasone and 4 mg of ondansetron intraoperatively. The primary outcome was nausea (numeric rating scale >3) and/or vomiting 24 h after discharge. Secondary outcomes included nausea and vomiting in the post-anaesthesia care unit (PACU), severe nausea, vomiting and side effects. Normality was assessed using the Shapiro-Wilk test, and the independent samples t-test or the Mann-Whitney U test was used to compare continuous variables. Fisher's exact test was used to assess any non-random associations between the categorical variables. Results: The incidence and severity of postoperative nausea and vomiting were similar in both groups within PACU (four patients experienced nausea and vomiting, three had severe symptoms in Group O, P = 0.057) and in the post-discharge period (three patients in Group O had nausea and vomiting compared to five patients in Group C, of which four were severe, P = 0.484). The side effects (sedation, dizziness, and light-headedness) were comparable between the two groups. Conclusion: A single preoperative oral olanzapine can be an effective alternative to standard antiemetic prophylaxis involving dexamethasone and ondansetron for preventing PDNV in highly emetogenic daycare surgeries with propofol-based GA.

A comparison of three vasopressors for tight control of maternal blood pressure during cesarean section under spinal anesthesia: Effect on maternal and fetal outcome.

PURPOSE: Maintaining systolic blood pressure (SBP) at 100% of baseline is best for fetal and maternal outcome. We hypothesized that irrespective of the vasopressor used, maintaining SBP at 100% of baseline with phenylephrine (P), metaraminol (M), or ephedrine (E) will produce the best fetal pH after cesarean section (LSCS) under subarachnoid block (SAB). MATERIALS AND METHODS: Ninety ASA 1 women scheduled for elective LSCS were randomly allocated to receive P, M, or E. SAB was established with patient in left lateral position using 2.5 cc of 0.5% hyperbaric bupivacaine. Immediately following SAB, patients received a bolus of the study drug (E = 5 mg, M = 0.5 mg, P = 30 mcg) followed by infusion (E = 2.5 mg/min, M = 0.25 mg/min, P = 15 mcg/min) to maintain SBP at 100% baseline. Umbilical blood gases, maternal hemodynamic parameters, and complications were recorded. RESULTS: The umbilical pH was comparable in all the three groups (P > 0.05). The mean SBP from spinal block until delivery was similar over time for all the three groups. The incidence of reactive hypertension was more in group M (P < 0.05) than in group E and group P. Total drug consumption to meet target blood pressure till delivery was 39.3 ± 14.6 mg in group E, 1.7 ± 0.9 mg in group M, and 283.6 ± 99.8 mcg in group P. The incidence of nausea and vomiting was comparable in the three groups. CONCLUSION: All the three vasopressors were equally effective in maintaining maternal blood pressure as well as umbilical pH during spinal anesthesia for cesarean section without any detrimental effects on fetal and maternal outcome.

Cephalometric evaluation of pharyngeal airway and tongue space following treatment with Herbst and AdvanSync appliances : A prospective randomized clinical trial.

OBJECTIVES: To evaluate and compare pharyngeal airway and tongue space changes after treatment with fixed functional appliances-Herbst and AdvanSync™ (Ormco, Orange, CA, USA) appliances-in skeletal class II patients in pre- and posttreatment lateral cephalograms. METHODS: For this randomized, controlled trial, 40 patients (21 male, 19 female) were divided into two groups-a Herbst group (mean age 12.6 ± 0.67 years) and an AdvanSync group (mean age 12.8 ± 0.66 years). Pre- and posttreatment (appliance therapy duration-8 months) lateral cephalograms were traced using a software program to evaluate pharyngeal airway and tongue space changes. RESULTS: Nasopharyngeal airway, velopharyngeal airway, glossopharyngeal airway, and hypopharyngeal airway increased in the Herbst group by 2.12 mm (p ≤ 0.001), 2.33 mm (p ≤ 0.001), 2.40 mm (p ≤ 0.01), and 1.57 mm (p ≤ 0.05), while in the AdvanSync group the increases were 1.89 mm (p ≤ 0.001), 1.21 mm (p ≤ 0.001), 1.18 mm (p ≤ 0.001), and 1.53 mm (p ≤ 0.001), respectively. In the Herbst group, tongue length and height increases were 2.04 mm (p ≤ 0.01) and 3.74 mm (p ≤ 0.001), while the values in the AdvanSync group were 2.41 mm (p ≤ 0.05) and 2.69 mm (p ≤ 0.001). The change of the tongue tip from the lower occlusal plane was 0.69 mm (p ≤ 0.001) in the Herbst group and 0.77 mm (p ≤ 0.001) in the AdvanSync group. The velopharyngeal airway dimension was correlated positively with that of the retroglossal oropharyngeal airway, which in-turn positively correlated with the laryngopharyngeal airway which correlated well with the distance of the tongue tip from the lower occlusal plane. CONCLUSIONS: The airway dimensions and tongue parameters increased significantly in both treatment groups in the present study. These changes were higher in the Herbst appliance than in the AdvanSync group, except for the distance of the tongue tip from the lower occlusal plane. A significant difference between the pharyngeal airways was found only for the retropalatal oropharyngeal airway.

Efficacy of serratus anterior plane block versus thoracic paravertebral block for postoperative analgesia after breast cancer surgery - a randomized trial.

BACKGROUND: Breast cancer surgery is associated with considerable acute post-surgical pain and restricted mobility. Various regional and neuraxial anesthesia techniques have been used to alleviate post-mastectomy pain. Ultrasound-guided serratus anterior plane block (SAPB) has been considered a simple and safe technique. This randomized control study was performed to compare the efficacy of SAPB with the thoracic paravertebral block (TPVB) for postoperative analgesia after breast cancer surgery. METHODS: A total of 40 adult ASA physical status I - II female patients undergoing radical mastectomy were randomly allocated into two groups to receive either ultrasound-guided TPVB or SAPB with 0.4 mL.kg-1 0.5% ropivacaine, 30 min before surgery. All patients received standardized general anesthesia for surgery. Injection diclofenac and tramadol were used for postoperative rescue analgesia. The time to first rescue analgesia, total analgesic consumption in the first 24 hours, postoperative pain scores, and any adverse effects were recorded. RESULTS: The time to first rescue analgesia was significantly longer in the SAPB group (255.3 ±â€¯47.8 min) as compared with the TPVB group (146.8 ±â€¯30.4 min) (p < 0.001). Total diclofenac consumption in 24 hours was also less in the SAPB group (138.8 ± 44.0 mg vs 210.0 ± 39.2 mg in SAPB and TPVB group respectively, p < 0.001). Postoperative pain scores were significantly lower in the SAPB group as compared with TPVB group (p < 0.05). The incidence of PONV was also less in the SAPB group (p = 0.028). No block-related adverse effects were reported. CONCLUSION: We found that the serratus anterior plane block was more effective than the thoracic paravertebral block for postoperative analgesia after breast cancer surgery.

Atlanto-axial instability in achondroplastic dwarfs: a report of two cases and literature review.

BACKGROUND: Achondroplasia is the commonest form of human dwarfism. The authors report atlanto-axial instability, in consequence to os odontoideum in this subgroup of patients. METHODS: Two achondroplastic dwarfs harboring atlanto-axial dislocation are described along with radiological findings. RESULTS: Both children underwent successful internal rigid immobilization, using sublaminar atlanto-axial wiring. CONCLUSIONS: Craniovertebral junction instability should be evaluated among these children, whenever foramen magnum insufficiency is being considered.

Efficacy of erector spinae plane block for postoperative analgesia in total mastectomy and axillary clearance: A randomized controlled trial.

BACKGROUND: The erector spinae plane block is a newer technique of analgesia to the chest wall. OBJECTIVE: The study was carried out to establish the efficacy and safety of this block in patients undergoing total mastectomy and axillary clearance. DESIGN: Prospective randomized controlled study. SETTING: Single tertiary care center, the study was conducted over a period of 1 year. PATIENTS: 65 patients were included; final analysis was done for 60 female patients undergoing total mastectomy and axillary clearance under general anesthesia were randomly allocated to two groups. INTERVENTION: Group B (block group) received ultrasound-guided erector spinae plane block at T5 level with ropivacaine (0.5%, 0.4 mL/kg) while the control group did not receive any intervention. Postoperatively, patients in both groups received morphine via intravenous patient-controlled analgesia device. Patients were followed up for 24 h postoperatively. MAIN OUTCOME MEASURES: The 24-hour morphine consumption was considered as the primary outcome and secondary outcomes included time to first rescue analgesia, pain scores at 0, ½, 1, 2, 4, 6, 8, 12, and 24 h and characteristics and complications associated with block procedure. RESULTS: The 24-hour morphine consumption was 42% lower in block group compared to control group [mean (SD), 2.9 (2.5) mg vs 5.0 (2.1) mg in group B and group C, respectively, P = 0.01]. The postoperative pain score was lower in group B vs group C at 0, 1/2, 1, 2, 4, 6, 12, and 24 h (P < 0.05). 26 patients in group C against 14 in group B used rescue analgesia within 1 h of surgery (P = 0.01). CONCLUSION: Erector spinae block may prove to be a safe and reliable technique of analgesia for breast surgery. Further studies comparing this technique with other regional techniques are required to identify the most appropriate technique.

Keyhole anesthesia-Perioperative management of subglottic stenosis: A case report.

Any narrowing in the airway presents as obstruction and with features of noisy breathing. The presence of subglottic stenosis poses a great challenge to the anesthesiologist. Diagnostic and corrective procedures by Otolaryngologist require rigid endoscopy which demands apneic ventilation. Hence, the goal of general anesthesia in the presence of subglottic stenosis requires a patent airway to maintain oxygenation and ventilation and avoid hypoxia. We present an interesting case of a preterm neonate with subglottic stenosis who was managed successfully with endoscopic release.

Dexmedetomidine versus propofol at different sedation depths during drug-induced sleep endoscopy: A randomized trial.

OBJECTIVES/HYPOTHESIS: The aim of this study was to compare the effect of dexmedetomidine and propofol on airway dynamics, cardiorespiratory system, and emergence following drug-induced sleep endoscopy (DISE). STUDY DESIGN: Prospective, randomized, single-blinded study. METHODS: Sixty patients age 18 to 65 years in American Society of Anesthesiologists physical status groups 1 and 2 scheduled to undergo DISE were randomly allocated to either Group P (N = 30; receiving propofol infusion at 50-150 µg/kg/min) or Group D (N = 30; receiving dexmedetomidine bolus of 1 µg/kg followed by infusion at 0.5-1.0 µg/kg/hr). DISE was done at light sleep and deep sleep. Airway obstruction at tongue base was recorded as primary outcome. Airway obstruction at velum, oropharyngeal lateral wall, and epiglottis level during light and deep sedation, hemodynamic and respiratory parameters, time to attain sufficient sedation, time for emergence from sedation, and any adverse events during DISE with the two study drugs were recorded as secondary outcomes. RESULTS: There was a greater degree of obstruction at the tongue base level (P = 0.001) and Oropharynx level (P = 0.017) in Group P compared with Group D during deep sedation. Increase in airway obstruction from light to deep sleep was seen with propofol at the oropharynx (P = 0.0185) and tongue base (P = 0.0108) levels. Two patients (6.6%) in Group D and 10 patients (33.3%) in Group P showed oxygen saturation below the minimum oxygen saturation recorded during polysomnography. Time to open eyes to call after stopping sedation was significantly less in Group P (P = 0.005). CONCLUSIONS: Dexmedetomidine shows a lesser degree of airway collapse and higher oxygen saturation levels at greater sedation depth during DISE. Propofol has a faster onset and emergence from sedation. LEVEL OF EVIDENCE: 1b Laryngoscope, 130:257-262, 2020.

[Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine]. / Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina.

BACKGROUND AND OBJECTIVES: Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine. METHODS: A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S - control group received adductor canal block with 30mL saline, Group R - ropivacaine group received adductor canal block with 30mL of 0.375% ropivacaine and Group RC - clonidine group received adductor canal block with 30mL of 0.375% ropivacaine with clonidine 1µg.kg-1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting. RESULTS: The mean pain free periods were 20min, 384.76min and 558.09min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement. CONCLUSION: Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

[Efficacy of preoxygenation using tidal volume breathing: a comparison of Mapleson A, Bain's and Circle system]. / Eficácia da pré-oxigenação usando respiração em volume corrente: uma comparação dos sistemas Mapleson A, Bain e Circular.

BACKGROUND: Efficacy of preoxygenation depends upon inspired oxygen concentration, its flow rate, breathing system configuration and patient characteristics. We hypothesized that in actual clinical scenario, where breathing circuit is not primed with 100% oxygen, patients may need more time to achieve EtO2≥90%, and this duration may be different among various breathing systems. We thus studied the efficacy of preoxygenation using unprimed Mapleson A, Bain's and Circle system with tidal volume breathing at oxygen flow rates of 5L.min-1 and 10L.min-1. METHODS: Patients were randomly allocated into one of the six groups, wherein they were preoxygenated using either Mapleson A, Bain's or Circle system at O2 flow rate of either 5L.min-1 or 10L.min-1. The primary outcome measure of our study was the time taken to achieve EtO2≥90% at 5 and 10L.min-1 flow rates. RESULTS: At oxygen flow rate of 5L.min-1, time to reach EtO2≥90% was significantly longer with Bain's system (3.7±0.67min) than Mapleson A and Circle system (2.9±0.6, 3.3±0.97min, respectively). However at oxygen flow rate of 10L.min-1 this time was significantly shorter and comparable among all the three breathing systems (2.33±0.38min with Mapleson, 2.59±0.50min with Bain's and 2.60±0.47min with Circle system). CONCLUSIONS: With spontaneous normal tidal volume breathing at oxygen flow rate of 5L.min-1, Mapleson A can optimally preoxygenate patients within 3min while Bain's and Circle system require more time. However at O2 flow rate of 10L.min-1 all the three breathing systems are capable of optimally preoxygenating the patients in less than 3min.

The utility of targeted perioperative transthoracic echocardiography in managing an adult patient with anomalous origin of the left coronary artery-pulmonary artery for noncardiac surgery.

Congenital coronary artery anomalies as a whole are uncommon. Abnormal origin of the left coronary artery from the pulmonary artery (ALCAPA) is probably the most common congenital coronary defect. An overwhelming majority of the patients with untreated ALCAPA do not survive to adulthood. As yet, there is no consensus on the management of adults with ALCAPA. We describe a patient with breast malignancy and incidentally detected ALCAPA; primacy was given to treatment of the oncologic condition as a first step. Anesthesia management was focused on maintaining adequate collateral coronary perfusion and avoidance of excessive loading of the left ventricle. This was achieved using a simplified transthoracic echocardiography (TTE) protocol at the time of induction of anesthesia; TTE was also used to reconfirm the absence of disturbances in myocardial function at the end of surgery. We sugggest the routine use of tte in managing perioperative care in low resource settings when the underlying cardiac disease is rare and the evidence base if often insufficient.