Comparison of landmark guided and ultrasound guided percutaneous dilatational tracheostomy: Efficiency, efficacy and accuracy in critically ill patients.

Background and Aims: To overcome the procedure-related complications associated with landmark-guided percutaneous dilatational tracheostomy (PDT) ultrasound is emerging as a promising tool. Present study was designed to compare landmark-guided PDT and ultrasound-guided PDT in terms of efficiency, efficacy, and accuracy. Material and Methods: Hundred intensive care unit patients requiring prolonged mechanical ventilation were prospectively randomized into 2 groups of 50 patients each. In land mark guided (LMG) group, patients underwent landmark-guided PDT, whereas in ultrasound guided (USG) group, patients underwent ultrasound-guided PDT. Results: Both the groups were comparable in terms of demographic data, sequential organ failure assessment score, ventilator settings, and mean days on mechanical ventilation prior to PDT. The mean assessment time in the ultrasound-guided group (1.56 ± 1 min) was significantly more (P-value = 0.000) than in the landmark-guided group (0.84 ± 0.72 min). The mean total procedure time for the USG group (5.98 ± 10.23 min) was more than that for the LMG group (4.86 ± 8.03 min) (P-value 0.542). Deviation of puncture site from the midline was seen in two patients in group A as compared to none in the USG group (P-value = 0.153). The number of patients requiring more than one attempt for successful needle insertion was more (P-value = 0.148) in the LMG group (20%) as compared to USG group (8%). Incidence of complications, like bleeding and desaturation was more in the LMG group as compared to the USG group. Conclusion: Ultrasound-guided PDT is associated with reduction in periprocedural complications as compared to landmark technique, although it takes slightly longer time.

Dexmedetomidine vs dexamethasone as an adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block.

BACKGROUND AND AIMS: Both dexmedetomidine and dexamethasone have individually been shown to be beneficial as an adjuvant to ropivacaine. We compared the efficacy of combination of ropivacaine with dexmedetomidine and ropivacaine with dexamethasone in ultrasound-guided supraclavicular brachial plexus (SCBP) block. MATERIAL AND METHODS: In this prospective randomised double-blind controlled trial, 60 ASA physical status I/II patients undergoing elective upper-limb surgery under ultrasound-guided SCBP block with 30 ml of 0.5% ropivacaine were randomised into three groups. Group 1 (n = 20) received 1 µg/kg of dexmedetomidine, and group 2 (n = 20) received 8 mg of dexamethasone in addition to ropivacaine, while group 3 (n = 20) received only ropivacaine. The primary outcomes studied were onset and duration of sensory and motor block. Secondary outcomes included duration of analgesia, total analgesic consumption in 24 h postoperatively and quality of block. ANOVA and Chi-square test were used to compare results on continuous measurements and categorical measurements, respectively. RESULTS: Onset of sensory and motor block was faster in group 1 (13.5 ± 4.1 and 17.0 ± 4.1 min) and group 2 (15.6 ± 3.6 and 18.5 ± 3.7 min) as compared to group 3 (20.1 ± 5.3 and 24.9 ± 5.6 min; P < 0.001). Block duration was significantly longer in group 1 and group 2 than in group 3. Duration of analgesia was prolonged in group 1 and 2 (1218.0 ± 224.6 and 1128.0 ± 207.5 min, respectively) as compared to group 3 (768.0 ± 273.7 min; P < 0.001). Twenty-four hours analgesic consumption postoperatively was reduced in the two study groups. CONCLUSION: Both dexmedetomidine and dexamethasone when used as adjuvants to ropivacaine for SCBP block, block onset time, and prolong' block duration.

Premedication with pregabalin 150mg versus 300mg for postoperative pain relief after laparoscopic cholecystectomy.

BACKGROUND AND AIMS: Pregabalin has been used in various studies for postoperative pain relief in varying doses. However, there is no conclusive evidence to support a safe and effective dose of pregabalin. The present study was designed to compare the efficacy of two different preoperative doses of pregabalin (150 mg and 300mg) in patients undergoing laparoscopic cholecystectomy for postoperative pain relief. MATERIAL AND METHODS: Ninety adult patients of either sex with American Society of Anesthesiologist physical status I and II scheduled for elective laparoscopic cholecystectomy under general anesthesia were randomized to receive pregabalin 150mg (group A), pregabalin 300mg (group B), or placebo (group C) orally 1 h before surgery. The pain was assessed using a visual analog scale (VAS) and a verbal rating scale (VRS) for the initial 24 h postoperatively. The primary outcome of our study was the comparative assessment of the severity of pain in the postoperative period in three groups. Postoperative analgesic consumption and incidence of side effects were assessed as secondary outcome measures. RESULTS: VAS score was significantly more in group C than group A and B (P-value <0.05). The total amount of fentanyl required in 24 h was least in group B (228.33 ± 42.41µg) followed by group A (292.50 ± 46.49µg) and group C (322.50 ± 39.58µg) (P-value 0.0001). The incidence of sedation, dizziness, and visual disturbances was more in group B as compared to group A and was least in group C. CONCLUSIONS: Pregabalin 150 mg is effective in decreasing postoperative pain after laparoscopic cholecystectomy with fewer incidences of adverse effects such as sedation and visual disturbances as compared to pregabalin 300 mg.

Role of dexmedetomidine in early extubation of the intensive care unit patients.

BACKGROUND AND AIMS: Patients on ventilatory support in intensive care unit (ICU) require sedation and analgesia to facilitate mechanical ventilation and endotracheal tube tolerance. The selection of the agent should be such that it does not interfere with the early extubation of the patients. We compared the efficacy of dexmedetomidine with midazolam to facilitate extubation of patients from mechanical ventilation in terms of the sedative properties, cardiovascular responses, ventilation, and extubation characteristics and safety profile. MATERIALS AND METHODS: A total of 40 adult, mechanically ventilated patients of either sex, aged 18-60 years, meeting the standard criteria for weaning, randomized into 2 groups of 20 patients each, received intravenous infusion of dexmedetomidine (0.2-0.7 mcg/kg/h) or midazolam (0.04-0.2 mg/kg/h) as needed for Ramsay sedation scale 2-4. Extubation following standard extubation protocol was done. Time for extubation and vital parameters were regularly recorded. RESULTS: The time to extubation in the dexmedetomidine group was significantly lower than in the midazolam group. Heart rate and blood pressure was significantly lower in dexmedetomidine group than the midazolam group at most of the times. CONCLUSIONS: Dexmedetomidine has clinically relevant benefits compared with midazolam in facilitating extubation due to its shorter time to extubation, more hemodynamic stability, easy arousability, and lack of respiratory depression.

Intrathecal sufentanil or fentanyl as adjuvants to low dose bupivacaine in endoscopic urological procedures.

CONTEXT: Opioids are being increasingly used these days as adjuvants to local anesthetics in spinal anesthesia. AIM: The aim of this study is to compare the effects of adding sufentanil or fentanyl to low dose bupivacaine in spinal anesthesia for endoscopic urological procedures. SETTINGS AND DESIGN: Prospective, randomized, double-blind study. MATERIALS AND METHODS: A total of 90 elective endoscopic urological surgery patients, 40-80 years old, received spinal anesthesia with 7.5 mg hyperbaric bupivacaine 0.5% (Group A) or by adding sufentanil 10 g (Group B) or fentanyl 25 g (Group C) to 5 mg hyperbaric bupivacaine 0.5%. These groups were compared in terms of the quality of spinal anesthesia as well as analgesia. RESULTS: The onset of sensory and motor blockade was significantly rapid in Group A as compared with Groups B and C. The maximum upper level of sensory block was higher in Group A patients than Groups B and C patients. Quality of analgesia was significantly better and prolonged in sufentanil group as compared with other two groups. Motor block was more intense and prolonged in Group A as compared with Groups B and C patients. Request for post-operative analgesic was significantly delayed in Group B patients. CONCLUSIONS: Spinal anesthesia for endoscopic urological procedures in elderly patients using low dose bupivacaine (5 mg) combined with 10 µg sufentanil is associated with a lower incidence of hemodynamic instability, better quality and prolonged duration as compared to that by adding 25 µg fentanyl.

Optimal positioning of right internal jugular venous catheter: A randomised study comparing modified Peres' height formula and distance between insertion point and right third intercostal space.

Background and Aims: The position of the tip of the central venous catheter (CVC) is important to minimise complications. The aim of our study was to compare modified Peres' height formula and landmark method using distance between puncture site and right third intercostal space (PS-RTICS) and to develop a reliable formula for correct positioning of tip of the CVC. Methods: This prospective, randomised study was conducted on 400 patients of either gender, of age 18 years and older, scheduled to undergo right internal jugular venous cannulation. Depending on the technique used for deciding the length of CVC to be inserted, the patients were randomly allocated into two groups: Group A, using modified Peres' height formula, that is, height of patient (cm)/10-2 and Group B, using distance between PS-RTICS and subtracting one from it, that is (PS-RTICS)-1. The carina was taken as the landmark for optimum insertion of CVC, which was confirmed on postprocedure chest X-ray. Data so obtained were tabulated and analysed. P<.05 was considered statistically significant for correlation and regression coefficients. Results: In group A, the mean length of catheter inserted was 15.18 ± 0.73 cm and the catheter tip was found to be 2.41 ± 0.85 cm distal to carina (P =0.001). Over-insertion was found in 98.45% patients in group A. In group B, the mean length of catheter inserted was 14.12 ± 0.85 cm and the catheter tip was found to be 0.20 ± 1.18 cm distal to carina. Conclusion: Though both landmark and modified Peres' height formula has low accuracy, landmark technique is superior in predicting correct depth of right internal jugular venous cannulation catheter.

Comparison of Intra-articular Analgesia and Femoral Nerve Block for Postoperative Pain Relief in Unilateral Total Knee Arthroplasty: A Randomized Clinical Study.

BACKGROUND AND AIMS: Femoral nerve block (FNB) and intra-articular analgesia (IAA) are used for postoperative analgesia after total knee arthroplasty (TKA). AIMS AND OBJECTIVES: We aimed to determine the better technique among the two, with regard to duration and quality of postoperative analgesia along with 24-h rescue analgesic consumption. The functional recovery in the early postoperative period was also assessed. SETTINGS AND DESIGN: This was a prospective double-blind study comprising 40 American Society of Anesthesiologists I-III patients undergoing elective TKA who were randomly assigned to two groups (n = 20). METHODOLOGY: In Group A, 20 mL ropivacaine 0.5%, containing dexmedetomidine (1 µg.kg - 1), was given by FNB, and in Group B, intra-articular administration of the same drug was done. Analgesic effect was evaluated by measuring the Visual Analog Scale (VAS) and duration of analgesia. Quadriceps muscle strength was noted. STATISTICAL ANALYSIS: Observation data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann-Whitney rank test. RESULTS: The mean VAS on passive movement at the 2nd, 6th, and 16th h postoperatively was 1.75 ± 0.44, 2.90 ± 0.72, and 2.75 ± 0.44 in Group A as compared to 2.25 ± 0.72, 4.30 ± 2.05, and 2.20 ± 0.77 in Group B (P = 0.026, 0.043, and 0.014, respectively). In Group A, the first request for analgesic (rescue analgesic) was at 637 ± 119 min and the total consumption of tramadol was 50.00 mg. In Group B, the first request for analgesic was at 404.44 ± 136 min, with a total dose of 63.89 mg. The Pvalue for the time of rescue analgesic was <0.001, while for total drug consumption, it was 0.018. CONCLUSION: We concluded that the duration and quality of analgesia (VAS) were significantly superior and rescue analgesic requirement less in patients who received FNB as compared to IAA.

Dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block.

CONTEXT: Dexmedetomidine as an adjuvant to local anesthetics in peripheral nerve blocks has been used in only a few studies. AIMS: We aimed at assessing the effect of dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block. SETTINGS AND DESIGN: Random, controlled, and triple blind. MATERIALS AND METHODS: Sixty American Society of Anesthesiologist grade I and II patients of either sex scheduled for elective upper limb surgery under supraclavicular brachial plexus block were divided into three equal groups in a prospective randomized double-blind controlled manner. For block patients in Group C received 0.5% ropivacaine (30cc), 0.5% ropivacaine with 50 µg dexmedetomidine (30cc) in Group D and 0.5% ropivacaine (30cc) in Group D-IV along with intravenous infusion of 50 µg dexmedetomidine in normal saline. STATISTICAL ANALYSIS USED: IBM-SPSS software version 17, Chi-square test, Mann-Whitney U-test. RESULTS: Demographic profile and surgical characteristics were similar in all the three groups. Sensory block and motor block onset was earlier in group D than in group D-IV and group C. The sensory block and motor block duration was also prolonged in group D when compared with group D-IV and group C. The duration of analgesia was significantly longer in group D and D-IV when compared to group C. CONCLUSIONS: Dexmedetomidine as an adjuvant to 0.5%ropivacaine in ultrasound guided brachial plexus block shortens the sensory as well as motor block onset time, prolongs sensory and motor block duration and also increases the duration of analgesia. The action of dexmedetomidine most probably is local rather than centrally mediated.

A comparative evaluation of intrathecal bupivacaine alone, sufentanil or butorphanol in combination with bupivacaine for endoscopic urological surgery.

BACKGROUND: The objective of the present study was to compare the onset, degree and recovery time of sensory and motor block and hemodynamic effects of intrathecal bupivacaine alone and bupivacaine with sufentanil or butorphanol in endoscopic urological surgeries. METHODS: In a randomized, double-blind study, 90 patients of either sex and age, belonging to ASA Grades I and II, scheduled for elective endoscopic urological surgeries under spinal anesthesia, were allocated into three groups of 30 each. Patients received either 2.5 ml of 0.5% hyperbaric buypivacaine 12.5 mg (Group A), 1.5 ml of 0.5% hyperbaric bupivacaine 7.5 mg with 10 µg sufentanil (Group B) or 1.5 ml of 0.5% hyperbaric bupivacaine 7.5 mg with 25 µg butorphanol (Group C). Vital parameters, level, duration and regression of sensory block and motor block and side-effects were recorded and compared. STATISTICAL ANALYSIS: Analysis of variance (ANOVA), post hoc test and Chi-square test were used. RESULTS: Intrathecal addition of sufentanil/butorphanol prolonged the duration of sensory block (DOSB) compared with bupivacaine alone (DOSB being 156.83±23.83 min, 170.87 ± 22.21 min and 171.17 ± 23.99 min in groups A, B and C, respectively) without altering the duration of motor blockade. Bromage score 3 was achieved in 100%, 90% and 54.4% patients in groups A, B and C, respectively. The time to first request for analgesia was 112 ± 46.3 min, 323 ± 65.0 min and 299 ± 73.9 min in groups A, B and C, respectively. Complications were reduced by the addition of butorphanol, which also has a lower tendency than sufentanil to produce pruritus (60%). CONCLUSIONS: The analgesia was significantly prolonged in groups B and C; group C had a less-intense motor block. Complications were reduced by the addition of butorphanol, which also has a lower tendency than sufentanil to produce pruritus. Thus, this combination of butorphanol with low-dose bupivacaine is especially beneficial in the geriatric group of patients who have multiple co-morbid conditions.

Bier's block using lignocaine and butorphanol.

BACKGROUND: Opioids are most commonly used as adjuncts in intravenous regional anesthesia (IVRA) to improve the quality of intraoperative and postoperative analgesia. There is paucity of literature on the use of butorphanol in IVRA. AIMS: The aim of this study was to evaluate the likely benefits of addition of butorphanol to lignocaine in Bier's block in terms of onset and duration of sensory block and also for analgesic requirement in postoperative period. SETTINGS AND DESIGN: A randomized double blind study was conducted at Tertiary Care Educational Institute. PATIENTS AND METHODS: A total of 40 adult ASA I or II patients scheduled to undergo upper limb surgery were randomized in two groups (n=20). Group I received 3 mg/kg of lignocaine alone and group II received 1 mg butorphanol in addition to 3 mg/kg lignocaine. Sensory block onset time and time to recovery from sensory block after tourniquet deflation were noted using the pin prick method. Duration of postoperative analgesia was noted using a visual analogue scale. All the patients were compared for the time to first rescue analgesic consumption and total analgesic consumption in first 24 hours postoperatively. STATISTICAL ANALYSIS USED: The statistical analysis was done using unpaired Student's t-test. RESULTS: Our study showed significant prolongation of postoperative analgesia in group II as noted by the time to first analgesic requirement. Total analgesic consumption in first 24 hours postoperatively was less in group II. Sensory block onset time and time to recovery from sensory block after tourniquet deflation, did not show any significant difference between the two groups. CONCLUSIONS: Addition of butorphanol to lignocaine in IVRA significantly prolongs the duration of postoperative analgesia and 24 hours analgesic consumption is less in patients receiving butorphanol along with lignocaine in IVRA. However, there is no effect on sensory block onset time and time to recovery from sensory block.

Distance from Skin to Epidural Space: Correlation with Body Mass Index (BMI).

BACKGROUND: Epidural anaesthesia is being increasingly used to provide anaesthesia for surgery on the lower abdomen, perineum and lower extremities. However success of the epidural technique depends upon the correct identification of epidural space.2 We conducted a study to find the distance from skin to the epidural space and its correlation with body mass index, to improve the success rate. PATIENT AND METHODS: 120 adults patients belonging to ASA physical status I and II in the age group of 18-70 years, scheduled for surgery and or pain relief under epidural block, were taken up for the study. 60 patients of either sex were further subdivided into 2 subgroups of 30 patients each having BMI less than 30 or more than 30. The distance from skin to epidural space was measured as the distance between rubber marker and tip of Tuohy's needle. RESULTS: It was found that with increase in Body mass Index, the distance from skin to the epidural space also increases. The distance from the skin to the epidural space does not depend on the age or the sex of the patients. CONCLUSIONS: WE FORMULATED PREDICTIVE EQUATION OF DEPTH OF EPIDURAL SPACE FROM SKIN IN RELATION TO BMI BASED ON LINEAR REGRESSION ANALYSIS AS: Depth (mm) = a + b (BMI). Where a = 17.7966 and b = 0.9777.