Utility of non-invasive haemoglobin monitoring in oncosurgery patients.

BACKGROUND AND AIMS: Oncosurgeries may incur massive blood loss demanding frequent blood sampling to assess blood loss and the need for intraoperative blood transfusions. Accuracy of non-invasive spectrophotometric haemoglobin (hereafter to be referred as SpHb) monitoring has been studied in various perioperative settings. The intraoperative use of Radical-7®, Masimo Corp., (Radical-7®) for SpHb monitoring may be useful during cancer surgery. The aim of this study is to evaluate the intraoperative utility of SpHb monitoring by the Radical-7® to guide intraoperative transfusion in oncosurgeries. METHODS: Fifty adult patients, undergoing oncosurgery with anticipated blood loss of more than 20% of blood volume, were selected. Continuous SpHb monitoring was performed intraoperatively and blood transfusion was based on SpHb values. Simultaneous laboratory haemoglobin (LabHb) samples were taken for validation. The accuracy of intraoperative blood transfusions based on SpHb was analysed using Error Grid Analysis. Paired measurements of SpHb and LabHb were compared using Bland-Altman plot analysis. RESULTS: There were 66 paired data points for blood transfusion from fifty patients with a correlation of 73% (P < 0.001) between SpHb and LabHb. In the Bland-Altman analysis, the bias was - 0.313 g/dl with ~ 95% of values within the limits of agreement of 1.81 g/dl to -2.44 g/dl. In the Error Grid Analysis, most data points were in the least error zone (Zone A). CONCLUSION: The Radical-7® has the advantage of providing SpHb value continuously to take prompt decision regarding blood transfusion intraoperatively.

Comparison of volume controlled ventilation and pressure controlled ventilation in patients undergoing robot-assisted pelvic surgeries: An open-label trial.

BACKGROUND AND AIMS: Although volume controlled ventilation (VCV) has been the traditional mode of ventilation in robotic surgery, recently pressure controlled ventilation (PCV) has been used more frequently. However, evidence on whether PCV is superior to VCV is still lacking. We intended to compare the effects of VCV and PCV on respiratory mechanics and haemodynamic in patients undergoing robotic surgeries in steep Trendelenburg position. METHODS: This prospective, randomized trial was conducted on sixty patients between 20 and 70 years belonging to the American Society of Anesthesiologist Physical Status I-II. Patients were randomly assigned to VCV group (n = 30), where VCV mode was maintained through anaesthesia, or the PCV group (n = 30), where ventilation mode was changed to PCV after the establishment of 40° Trendelenburg position and pneumoperitoneum. Respiratory (peak and mean airway pressure [APpeak, APmean], dynamic lung compliance [Cdyn] and arterial blood gas analysis) and haemodynamics variables (heart rate, mean blood pressure [MBP] central venous pressure) were measured at baseline (T1), post-Trendelenburg position at 60 min (T2), 120 min (T3) and after resuming supine position (T4). RESULTS: Demographic profile, haemodynamic variables, oxygen saturation and minute ventilation (MV) were comparable between two groups. Despite similar values of APmean, APpeak was significantly higher in VCV group at T2 and T3 as compared to PCV group (P < 0.001). Cdyn and PaCO2 were also better in PCV group than in VCV group (P < 0.001 and 0.045, respectively). CONCLUSION: PCV should be preferred in robotic pelvic surgeries as it offers lower airway pressures, greater Cdyn and a better-preserved ventilation-perfusion matching for the same levels of MV.

A Prospective Evaluation of Symptom Prevalence and Overall Symptom Burden Among Cohort of Critically Ill Cancer Patients.

BACKGROUND: Gross physiological perturbations necessitating the Intensive Care Unit (ICU) admission might exacerbate the already existing or initiate bothersome symptoms among cancer patients. There is a lack of conclusive evidence concerning the symptomatic experience among this subgroup of cancer patients particularly so in the Indian population. The aim of this prospective observational study was to elucidate the symptom prevalence and overall symptomatic distress among critically ill cancer patients at the time of admission to a medical ICU. METHODS: We prospectively evaluated 110 consecutive cancer patients at the time of admission to our medical ICU for the presence and intensity of symptoms using a modified Edmonton Symptom Assessment Scale (ESAS). The patients/caregivers were also enquired regarding the most bothersome symptom in the past 1 week and the presence of "symptom associated sleep disturbance." The primary outcome was the prevalence of patients with moderate (ESAS ≥ 40) and severe (ESAS ≥ 70) symptomatic distress. RESULTS: The average age was 52.49 years with 75.45% of the respondents in the economically productive age group (21-60 years). Carcinoma breast (19.35%) and lung (14.58%) were the most common cancers among females and males, respectively. 87.27% and 60% of the patients had advanced cancer and multi-organ dysfunction, respectively. About 76.36% patients were able to complete ESAS either by themselves or with caregiver's assistance within first 24 h of ICU admission. The mean ESAS distress score was 48.04 (0-81) with 72.72% of the patients having moderate-severe symptomatic distress. Loss of appetite (92.73%) and nausea (54.55%) were the most common and the least common reported symptoms, respectively. Pain was the most common and "most distressing symptom" reported by 40% of patients with 64.55% patients reporting one or more symptoms severe enough to interfere with their sleep. CONCLUSION: ESAS is a user-friendly cognitive aid to make the healthcare team cognizant of the symptom existence and overall symptomatic burden among cancer patients with gross physiological perturbations. The high prevalence of moderate-severe symptom distress requires the concomitant provision of palliative and intensive care among this group of cancer patients.

The Prevalence and Characteristics of Pain in Critically Ill Cancer Patients: A Prospective Nonrandomized Observational Study.

CONTEXT: Pain is a distressing symptom common to all stages and ubiquitous at all levels of care in cancer patients. However, there is a lack of scientific literature on prevalence, severity, predictors, and the quality of pain in cancer patients admitted to an Intensive Care Unit (ICU). OBJECTIVES: To elucidate the prevalence of pain, moderate to severe pain, neuropathic pain, chronic pain, and pain as the most distressing symptom in critically ill-cancer patients at the time of ICU admission. METHODS: We prospectively interviewed 126 patients within first 24 h of admission to a medical ICU. The patients were assessed for the presence of pain, its severity, sites, duration, nature, and its impact as a distressing symptom. Numerical Rating Scale and self-report version of Leeds Assessment of Neuropathic Signs and Symptoms were used to elucidate intensity of pain and neuropathic pain, respectively. Demographic characteristics such as age and sex, primary site, and stage of cancer were considered for a possible correlation with the prevalence of pain. RESULTS: Of 126 patients included in the study 95 (75.40%), 79 (62.70%), 34 (26.98%), and 17 (13.49%) patients had pain, moderate-severe, chronic, and neuropathic pain, respectively. The average duration of pain was 171.16 ± 716.50 days. Totally, 58 (46.03%) and 42 (42.01%) patients had at least one and more than equal to 2 neuropathic pain symptoms, respectively. The primary malignancies associated with the highest prevalence of pain were genitourinary, hematological, and head and neck whereas breast and lung cancers were associated with the highest prevalence of neuropathic and chronic pain, respectively. CONCLUSION: The prevalence of pain among critically ill-cancer patients is high. Assessment for pain at the time of ICU admission would ensure appropriate assessment for the presence, type, severity, and the significance imparted to it.

Anesthesia for hemicolectomy in a known porphyric with cecal malignancy.

Intraoperative management of a known acute intermittent porphyria patient is a challenge requiring awareness of factors, which trigger an acute crisis, clinical features of a porphyric attack, knowledge of safe pharmacologic intervention, and preparedness for reintubation and ventilatory support. The classical signs of a porphyric crisis such as pain abdomen, vomiting and neuropsychiatric symptoms are masked under general anesthesia and can be confused with postoperative pain and vomiting and postoperative cognitive dysfunction, especially for intra-abdominal surgeries. Eternal vigilance for onset of an acute crisis is imperative. After a crisis of acute intermittent porphyria, residual paresis may persist for years in the absence of further attacks.

Evaluation of length of central venous catheter inserted via cubital route in Indian patients.

AIM: Peripherally inserted central venous catheters (PICCs) are popular due to the ease of insertion, low cost and low risk of complications. Anteroposterior (AP) chest radiograph (CXR) is then obtained to assess the location of the catheter tip. But poor-quality X-rays remain a significant problem. We planned a study using radiopaque marker at sternal angle, as a radiological landmark, to relate height of the patient and optimal length of PICC fixation, at the antecubital fossa, and to know the incidence of malpositioning. MATERIALS AND METHODS: A total of 200 patients aged above 20 years, scheduled for elective major cancer surgeries were studied. Vygoflex PUR, 16-G catheter, length 70 cm was used. The right or the left arm was chosen depending on the availability of veins. Catheter tip was observed in the post procedure CXR. RESULTS: 200 patients [100 patients in group 1 (length of catheter fixation at antecubital fossa 45 cm) and 100 patients in group 2 (length of catheter fixation 50 cm)] were enrolled. The groups were further subdivided into 1a, 1b, 2a, 2b and results tabulated. CONCLUSIONS: Appropriate length of catheter fixation for group 1a was <45 cm, group 1b = 45 cm, group 2a = 50 cm, and for group 2b it was ≥50 cm. Gender and arm (right or left) did not have any bearing on the length of fixation. Incidence of malpositioning (15.5%) was more in right-sided catheters, more so, in short heighted people. PICC insertion via cubital route stands better compared with other routes, viz., Internal jugular vein IJV, subclavian and femoral.

Walking Epidural : An Effective Method of Labour Pain Relief.

BACKGROUND: Labour pain can be deleterious for mother and baby. Epidural analgesia relieves labour pains effectively with minimal maternal and foetal side effects. A prospective open label study was undertaken to ascertain effective dosing regime for walking epidural in labour. METHODS: Fifty women with singleton foetus in vertex position were included. Epidural catheter was inserted in L2-3 / L3-4 interspinous space. Initial bolus of 10 ml (0.1% bupivacaine and 0.0002% fentanyl) solution was injected and after the efficacy of block was established, an epidural infusion of the same drug solution was started at the rate of 5 ml/hour. RESULTS: In first stage of labour 80% of the parturient had excellent to good pain relief (visual analogue scale 1 to 3) with standard protocol while 20% parturient required one or more additional boluses. For the second stage, pain relief was good to fair (VAS 4-6) for most of the parturient. The incidence of caesarian section was 4% and 6% needed assisted delivery. No major side effects were observed. CONCLUSION: 0.1% bupivacaine with 0.0002% fentanyl maximizes labour pain relief and minimizes side effects.

Correlation of bispectral index and Guedel's stages of ether anesthesia.

UNLABELLED: Bispectral index (BIS) analysis is a method of electroencephalograph (EEG) analysis based on the interfrequency phase relationships of the EEG, designed to quantify anesthetic hypnosis. The BIS was created after concurrent collection of EEG and clinical data from a large number of patients anesthetized with various drugs over a prolonged period and then performing a Fourier analysis followed by a bispectral calculation. The clinical stages of anesthetic depth are very well demonstrated in etherized patients. In this study, we studied the BIS changes during various stages of ether anesthesia and quantified the hypnotic depth during the surgical stage of ether anesthesia. The values for BIS under various stages and planes of ether anesthesia were recorded in 21 patients listed for short surgical procedures. During diethyl ether anesthesia, BIS initially increased and subsequently decreased. During surgical anesthesia, a BIS value of 30 was observed. IMPLICATIONS: For the first time, bispectral index (BIS) has been studied in patients being anesthetized solely with ether. Ether both causes an increase and decrease in BIS during induction and emergence. The index observed during the surgical stage of ether anesthesia is probably the correct value for the depth of hypnosis because no other volatile anesthetic can produce the true anesthetic state when used alone. This value could be taken as the value to be attained when balanced anesthesia is being practiced.

Cochlear Implant : Anaesthesia Challenges.

BACKGROUND: Cochlear implants are now an acceptable therapeutic option for those patients with irreversible hearing loss and deaf-mutism. The surgery is time consuming and complicated. Hence, the technique of anaesthesia plays a crucial role in success of cochlear implant surgery. Cochlear implant patients have various types of syndromes which are important from anaesthetic as well as surgical point of view. Pre-implant preparation requires objective assessment of hearing, plain X-rays of skull and a CT scan of the temporal bone. Anaesthesia is required for objective assessment of hearing in children under five years of age, to obtain X-rays of skull, magnetic resonance imaging (MRI), CT scan, brain evoked response audiometry (BERA) testing and finally for cochlear implant surgery. Anaesthetic considerations include preoperative familiarisation with the patient and his family. Syndromal illnesses have specific anaesthetic significance such as presence of difficult airway or prolonged QT interval. Parental presence is highly desirable during induction of anaesthesia. Electro-surgical instruments especially monopolar ones, should not be used once the cochlear implant is in place. METHODS: In our institution, all cases (15 children) received their cochlear implants under general anaesthesia and formed the study group. Children were administered midazolam orally and inj ketamine during CT scan. Our techniques of general anaesthesia were modified to permit use of nerve stimulators during surgery. To minimise the incidence of vertigo particularly after cochleostomy, postoperative nausea and vomiting, all patients received glycopyrrolate and fentanyl citrate intravenously prior to induction. Other agents used were, thiopentone, suxamethonium and end-tidal 1.3 MAC halothane in 1:2 mixture of oxygen and nitrous oxide (O2 and N2O). Electro diathermy was switched off, before the cochlear device was implanted on the patient. Patients were allowed to breathe spontaneously whenever nerve stimulator was used to locate the facial nerve. Inj Ondansetron 0.1 mg/kg was used as anti-emetic agent. Postoperative pain relief was initially provided with fentanyl 1 µg/kg IV and later with syrup ibuprofen. RESULTS: There were no remarkable anaesthetic or surgical complication in our series except perilymph leakage in two cases.

Quantification of urinary urate with alkylamine glass-bound uricase and arylamine glass-bound peroxidase.

Uric acid in urine was analyzed using porcine liver uricase and horseradish peroxidase immobilized on alkylamine and arylamine glass beads (pore diameter 55nm) respectively. The minimum detection limit was 5.0mg/0.1 ml urine. The recovery of added uric acid was 92%. Within and between assay CVS were <1.3% and <5.3% respectively. A good correlation (r=0.93) was found between urinary urate values obtained by a commercial kit method and the present method. The uric acid in 24hr urine of apparently healthy adults and person sufering from various diseases was found to be 450 to 900mg/24hr, 659mg/24hr (range, mean) and 910-1400mg/24hr, 1145 mg/24hr (range, mean) respectively with the present method.

Discrete analysis of serum uric acid with immobilized uricase and peroxidase.

Commercially available uricase and peroxidase have been immobilized onto alkylamine glass and arylamine glass beads respectively. A discrete method has been developed to determine uric acid in serum using immobilized uricase and peroxidase. The method is based on generation of H2O2 from serum uric acid by immobilized uricase and its measurement by a colour reaction catalyzed by immobilized peroxidase. The minimum detection limit of the method was 8 microg/0.1 ml sample. The mean analytical recovery of added uric acid in serum was 87.5%. The within and between assay coefficient of variation (C.V.) were <6.58% and <10.77% respectively. The serum uric acid in apparently healthy adults and persons suffering from different disease was found to be 25-55 microg/ml, 32+/-2.25 (range, mean+/-S.D.) and 55-200 microg/ml; 52+/-6.4 (range, mean+/-S.D.) respectively by our method. A good correlation (r = 0.8170) was obtained between the serum urate values by this method and with those obtained by commercial Enzo-kit method.

Parotid tuberculosis simulating malignancy.

An interesting case of parotid tumour simulating malignancy is reported. The rarity of this lesion and the associated clinical and diagnostic problems are emphasized together with the relevant literature.

Immobilization of sorghum leaf oxalate oxidase onto alkylamine and arylamine glass.

An oxalate oxidase (EC 1.2.3.4) purified from grain sorghum leaves was immobilized onto alkylamine and arylamine glass beads through glutaraldehyde coupling and diazotization with a conjugation yield of 10.8 mg/g support and 9.2 mg/g support, respectively. The enzyme retained 67.5% and 34.1% of its initial specific activity after immobilization onto alkylamine and arylamine glass, respectively. The enzyme exhibited an increase in optimum pH, temperature for maximum activity, energy of activation (Ea) and time for linearity but decrease in thermal stability at 60 degrees C after immobilization on both types of beads. The K(m) value for oxalate was increased by 9- to 10-fold but Vmax remained unaltered after immobilization. Both alkyl and arylamine glass bound enzyme was unaffected by physiological concentrations of Cl- and NO3-. The analytic importance of this work is demonstrated.

Immobilization of Amaranthus leaf oxalate oxidase on alkylamine glass.

A membrane bound oxalate oxidase from leaves of Amaranthus spionsus has been partially purified and immobilized on alkylamine glass with a yield of 9.2 mg protein/g support. The enzyme retained 99.4% of initial activity of free enzyme after immobilization. There was no change in the optimum pH (3.5) and Vmax but the temperature for maximum activity was slightly decreased (35 degrees C) and energy of activation (Ea) and Km for oxalate were increased after immobilization. The immobilized enzyme preparation was stable for 6 months, when stored in distilled water at 4 degrees C. Presence of Cl- did not affect the activity of immobilized enzyme.

Chemical analysis of urinary calculi in Haryana.

Quantitative chemical analysis of 225 urinary calculi (128 Renal, 57 bladder and 40 ureter) collected from hospitals of different districts of Haryana was carried out. CaOxM was found to be present as a major component in all the stones analysed, while MAP, HA, CA and UA were found in 83.7%, 83.6%, 13% and 78.9% cases, respectively. The content of CaOxM was found to be higher in renal stones as compared to ureter and bladder stones, while the concentration of MAP was higher in bladder stones as compared to kidney and ureter stones. HA content was higher in ureter and UA was higher in bladder stones as compared to other urinary stones.