Quantitative assessment of ultrasound-guided sciatic nerve block - A comparison of a single-point versus two-point injection technique: A randomised controlled, double-blinded trial.

Background and Aims: Sciatic nerve block at the popliteal level for lower limb procedures provides unpredictable success rates even with ultrasonographic (USG) guidance. This study aimed to compare USG-guided single-point versus two-point injection techniques. Methods: Sixty patients posted for foot surgeries under USG-guided sciatic nerve block were randomised into Group Single Point, receiving a single injection of 20 mL of 1.5% lignocaine with adrenaline just proximal to the sciatic nerve bifurcation, and Group Double Point, receiving two injections of 10 mL of 1.5% lignocaine with adrenaline, one at the point similar to the first group and a second injection 6 cm above the first point. Sensory blockade onset, time to complete sensory blockade, time to complete motor blockade, length of the nerve exposed and analgesia duration were evaluated. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) statistics version 20 software. Results: Double-point injection technique showed a significantly faster time to complete motor blockade [14.46 (9.93) min], increased length of nerve exposed to local anaesthetic [23.23 (7.209) cm] and extended duration of analgesia [420.40 (99.34) min] compared to the single-point injection technique [20.89 (12.62) min, 18.78 (5.95) cm and 344.28 (125.97) min, respectively]. The onset of sensory blockade and the time to complete sensory blockade were comparable between the two groups. Conclusion: USG-guided popliteal sciatic nerve block with a double-point injection technique does not significantly shorten the time to complete the sensory block. However, the time to complete motor nerve block and duration of analgesia are prolonged significantly, which may be clinically beneficial for postoperative analgesia.

Comparison of the Glottic Views in a Head Elevated Laryngoscopy Position with the Patient in Supine or 25º Backup: An Observer-Blinded Randomised Clinical Trial.

BACKGROUND: Simple manoeuvres such as Head elevated laryngoscopy position (HELP) can facilitate a better glottic view. We conducted this prospective randomized clinical trial to compare the glottic view in a head elevated laryngoscopy position with the same patient in supine and 25° backup position. METHODS: A total of 180 patients aged between 18-65 years, planned for elective surgery under general anaesthesia with endotracheal intubation using Macintosh laryngoscope were included. Any patient with anticipated airway difficulty, emergency surgeries or rapid sequence induction was excluded. All patients were randomized into two groups (Group B=90, Group S= 90). In group S, the glottic view was assessed while the patients were in 25° back up HELP position (1st position). Then the patients were repositioned and intubated in supine HELP (2nd position) position after reassessing the glottic view. In group B, the glottic view was assessed while the patients were in the supine HELP position (1st position). Then the patients were repositioned and intubated in 25° backup HELP position (2nd position) after reassessing the glottic view. Percentage of glottis opening score (POGO), Cormack Lehane (CL) Grade, laryngoscopy time, intubation time, attempts for intubation, anaesthesiologists comfort, use of ancillary devices/ manoeuvres and ease of intubation were recorded. RESULTS: The mean POGO score was significantly more in 25° backup than supine position (n=180; 25° backup HELP: 64.78 ±26.83 % vs Supine HELP: 46.96±27.71 %, p- value< 0.0001). The Cormack Lehane grade was significantly higher in the supine HELP position than 25° backup HELP position (n=180, p-value<0.0001). The mean laryngoscopy time was comparable between two positions (n=180, Supine with HELP: 9.38±3.80 sec, 25° backup with HELP: 9.47±3.80 sec; p-value: 0.608). The mean intubation time was significantly shorter (p-value: 0.001) in Group B (7.7±2.2 seconds) than Group S (9.2± 3.6 seconds). CONCLUSIONS: This study has shown that 25° backup HELP position provides improved glottic view in comparison to the supine HELP position.

Anesthesiologist in cardiac catheterization laboratory; the roles and goals!! A postgraduate educational review [corrected].

It is not uncommon to see in developing and underdeveloped countries, where the anesthesiologist who is untrained in cardiac specialty takes care of cardiac catheterization centers. The service in cardiac catheterization laboratories (CCL) in developed countries and some of the developing countries is mainly provided by the cardiac anesthesiologists. The scenario is not same in some part of developing countries or in underdeveloped countries which are mainly due to increase in number of CCL (catheterization laboratory) when compared to the number of cardiac anesthesiologists working outside the operation theater. It is also important for training the postgraduate in this field as to make them capable and competitive in managing such cases during emergency situation as it may save the life of a patient. Many a times, CCL is built as per the need of cardiologist ignoring the basic needs of cardiac anesthesiologist. It is important to note that anesthesiologist should be competent enough to provide complete, integrated anesthetic care outside the operation theater with available resources. It is challenging for the anesthesiologist to provide sedation or general anesthesia in such critical area where he/she will be dealing with life-threatening situations. In the modern era, the interventional techniques are advancing and treating complex heart diseases is more often. Days are not far where the CCL procedures may reduce the requirement of major surgeries. A careful and dedicated approach by the anesthesiologist with thorough knowledge and skills decreases morbidity and mortality rate. This article helps both cardiac and noncardiac anesthesiologists to improve their knowledge and to approach the patient systematically.

Evaluating the Efficacy of Tramadol as an Adjuvant to Intrathecal Isobaric Levobupivacaine for Elective Infraumbilical Surgeries.

BACKGROUND: Long-acting local anesthetics are used in subarachnoid block to increase the duration of anesthesia. Adjuvants are added to improve the duration of analgesia. SETTINGS: Randomized controlled trial was conducted in the Department of Anesthesiology in a tertiary care hospital. AIMS AND OBJECTIVES: The objective of this study was to evaluate the efficacy of low-dose tramadol as an intrathecal adjuvant to levobupivacaine in terms of duration of analgesia, onset of sensory blockade, onset of motor blockade, and duration of motor blockade. METHODOLOGY: After obtaining the Institutional Ethics Committee approval and informed consent, sixty patients posted for infraumbilical surgeries were recruited. Randomization was done using a sealed envelope technique. Patients were divided into two groups: LT received 3 ml of 0.5% isobaric levobupivacaine with tramadol 10 mg (0.2 ml) and LS received 3 ml of 0.5% isobaric levobupivacaine with 0.2 ml of normal saline. Duration of analgesia, onset of sensory blockade, and onset and duration of motor blockade were recorded. RESULTS: There was no statistical difference in demographic data between the two groups. The mean onset time of sensory blockade in Group LS was 12.7 ± 9.81 min and for Group LT was 12.9 ± 0.81 min, which was not statistically significant between two groups (P = 0.93). The mean onset time of motor blockade in Group LS was 13.4 ± 10 min and for Group LT was 14.4 ± 10 min, which was no statistically significant between the two groups (P = 0.71). The mean time duration of analgesia in Group LS was 170.3 ± 59 min and for LT was 198.9 ± 57.33 min. There was mild prolongation of analgesia in Group LT, but it was not statistically significant (P = 0.0615). The mean duration of motor blockade in Group LS was 170.23 ± 58 min and Group LT was 190.76 ± 4 min, which was not statistically significant between the two groups (P = 0.14). CONCLUSION: Low-dose tramadol as an adjuvant to isobaric intrathecal levobupivacaine does not prolong analgesia significantly.

Efficacy of Dexmedetomidine Infusion for Procedural Comfort and Intraoperative Sedation in Patients Undergoing Surgeries with Subarachnoid Block: A Randomized Double-blind Clinical Trial.

INTRODUCTION: There is increasing evidence to include sedation as an integral part of regional anesthesia to ensure patient comfort. This may compromise patient cooperation, an important component of regional anesthesia. We decided to determine the efficacy of dexmedetomidine (0.3 µg/kg/h and 0.5 µg/kg/h) for allaying procedural discomfort and ensuring their cooperation in patients undergoing surgery with subarachnoid block. SETTING: Tertiary care center. MATERIALS AND METHODS: Sixty patients with the American Society of Anesthesiologists physical status Class I and II posted for surgeries under subarachnoid block were randomized into two groups of 30 each to receive dexmedetomidine in a loading dose of 1 µg/kg in both groups followed by continuous infusion of 0.3 µg/kg/h in Group D 0.3 and 0.5 µg/kg/h in Group D 0.5. Observer assessment sedation score, ease of positioning score, response to spinal needle insertion, hemodynamic parameters, patient satisfaction (PS) score, and surgeon satisfaction (SS) score were evaluated. RESULTS: Median observer Assessment Sedation Score ranged between four and three at all times during dexmedetomidine infusion in Group D 0.3. In Group D 0.5, median Observer assessment of alertness/sedation scale ranged between three and two. Ease of positioning (P = 1.000) and response to spinal needle insertion (P = 0.521) were comparable in both groups. PS was higher in Group D 0.5 as compared to Group D 0.3. SS score was comparable in both the groups. CONCLUSION: Intravenous dexmedetomidine infusion 0.3 µg/kg/h produces effective sedation in patients undergoing surgery with spinal anesthesia while ensuring patient cooperation for positioning and without any recall of the procedure in postoperative period.

Comparison of King Vision and Truview Laryngoscope for Postextubation Visualization of Vocal Cord Mobility in Patients Undergoing Thyroid and Major Neck Surgeries: A Randomized Clinical Trial.

BACKGROUND: Visualization of vocal cords following extubation after thyroid and major neck surgeries is highly desirable for the surgeon as well as the anaesthesiologist to rule out vocal cord palsy or oedema. As the patient is emerging from general anaesthesia, it may be challenging for the anaesthesiologist to optimally visualise and grade vocal cord movement following extubation. SETTING: Randomized clinical trial at a tertiary care centre. METHODOLOGY: After obtaining institutional ethics committee approval, 60 patients posted for thyroid and major neck surgeries under American Society of Anesthesiologists (ASA) grade I and II were recruited for the study. Written informed consent was obtained. Pre-operatively indirect laryngoscopy was performed in all the patients to assess baseline vocal cord function. All patients were premedicated and induced and maintained as per standardized anaesthesia protocol. Patients were randomized using a sealed envelope technique to either Group K where intubation was performed using Kings vision laryngoscope or Group T where intubation was performed using True view laryngoscope. Glottis visualization was graded in all patients and intubated. Ten minutes prior to extubation injection. dexmedetomidine 1 µg/kg was administered. Once patients satisfied extubation criteria, laryngoscopy was performed using respective video-laryngoscope in each group, patient extubated under vision and assessed for vocal cord visualization and mobility grade (VMG) and patient reactivity score (PRS). Heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure was also noted. Total intraoperative morphine consumption was recorded. Vocal cord function was assessed again before the day of discharge by indirect laryngoscopy. RESULTS: Age (P = 0.27), sex (P = 0.08), body mass index (P = 0.70), ASA (P = 0.39), mallampati class (P = 0.72) and morphine used (P = 0.39) were comparable in both groups. There was no statistically significant difference among the two groups with respect to VMG (P = 0.18). There was no statistical difference in the PRS (P = 0.06) in both groups. Increase in heart rate or mean arterial pressure from baseline was not significant statistically in both groups. Time taken for laryngoscopy during extubation was significantly less with group T as compared to group K (P = 0.000). CONCLUSION: Both Kings Vision and Truview Video-laryngoscopes provide comparable laryngoscopic view with similar patient comfort, although clinically Truview may be a better choice due to less time consumed for visualisation and rating vocal cord movement during extubation.

Role of temporary pacing at the right ventricular outflow tract in anesthetic management of a patient with asymptomatic sick sinus syndrome.

A 60-year-old woman posted for percutaneous nephrolithotomy with ureterolithotripsy was found to have a history of hypertension and ischemic heart disease from past 6 months on regular treatment. Pulse rate was irregularly irregular in a range of 56-60/min, unresponsive to atropine, with a sinus pause on the electrocardiogram. Although the patient was asymptomatic, anticipating unmasking of the sick sinus syndrome during general anesthesia in the prone position, a temporary pacemaker was implanted at right ventricular outflow tract (RVOT) septum before the scheduled surgery. A balanced anesthesia technique with endotracheal intubation was administered. There were several episodes of continuous pacing by the temporary pacemaker intraoperatively, which may be attributed to unmasking of the sinus node dysfunction due to general anesthesia. At the end of surgery, patient was extubated after adequate reversal from neuromuscular blockade. Postoperative period remained uneventful, and the pacemaker wires were removed on the 2(nd) postoperative day. With this case report, we highlight the importance of inserting a temporary pacemaker prior to anesthesia even in an asymptomatic patient if a sinus node dysfunction is suspected preoperatively and if intraoperative access to transvenous pacing is difficult such as in prone position. Pacing at RVOT septum minimizes ventricular dyssynchrony and improves hemodynamic parameters.

Estimation of effect-site concentration of propofol for laryngeal mask airway insertion using fentanyl or morphine as adjuvant.

BACKGROUND AND AIMS: Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides jaw relaxation and suppression of upper airway reflexes. Propofol can provide these conditions especially when combined with narcotics. This study had been designed to find out the effect-site concentration (EC50) of propofol using target controlled infusion (TCI) when fentanyl or morphine is added as an adjuvant. METHODS: Patients satisfying inclusion criteria were divided into fentanyl and morphine groups. Intravenous glycopyrrolate 0.2 mg was given 15 min before induction. Patients were given either intravenous fentanyl (1 µg/kg) or morphine (0.1 mg/kg) before propofol infusion depending on the group. Patients in either groups were induced by continuous infusion of propofol at an EC of 6 µg/mL by TCI with Schneider pharmacokinetic model. The LMA supreme of appropriate size was inserted 1 min after achieving target concentration. Patient movement at LMA insertion or within 1 min of insertion was classified as failure. For subsequent patients, the target EC was increased/decreased depending on previous patients' response. Dixons up and down method was used to determine the EC50. The EC50 is defined as the mean of crossover midpoints in each pair of failure to success. RESULTS: The EC50 of propofol in the fentanyl group for LMA insertion was 5.95 ± 0.6 µg/ml and morphine group was 5.75 ± 0.8 µg/ml. No significant difference in insertion conditions was noticed between the two groups (P = 0.3). CONCLUSION: We conclude that there was no significant difference in propofol EC50 for insertion of LMA and insertion conditions were similar when fentanyl or morphine was used as an adjuvant drug.

Improved prophylaxis of postoperative nausea vomiting: Palonosetron a novel antiemetic.

Many anti-emetics are used in clinical practice. Palonosetron hydrochloride is one of them. It is a novel, centrally acting antiemetic, and anti-nausea agent. This drug is an antagonist of serotonin receptor subtype 3 (5-HT3). This drug has longer duration of action which makes it useful in the prevention and treatment of acute and delayed onset of nausea and vomiting. This drug was initially used for chemotherapy induced nausea and vomiting. Federal drug agency (FDA) has approved it for prevention and treatment of post-operative nausea and vomiting. The literature search for this article was done using Google scholar and Pubmed using the terms "Palonosetron," "longer duration of action," "nausea," "vomiting," and "postoperative".

Tapentadol hydrochloride: A novel analgesic.

Tapentadol is a novel, centrally acting analgesic with dual mechanism of action, combining mu-opioid receptor agonism with noradrenaline reuptake inhibition in the same molecule. It has an improved side effect profile when compared to opioids and nonsteroidal anti-inflammatory drugs. The dual mechanism of action makes Tapentadol a useful analgesic to treat acute, chronic, and neuropathic pain.

Sugammadex: A revolutionary drug in neuromuscular pharmacology.

Sugammadex (ORG 25969) is a unique neuromuscular reversal drug; a novel cyclodextrin, the first in a new class of selective relaxant binding agents, which reverse neuromuscular blockade (NMB) with the aminosteroid non-depolarizing muscle relaxants rocuronium and vecuronium. Sugammadex can reverse moderate or deep NMB. The clinical use of sugammadex promises to eliminate many of the shortcomings in current anesthetic practice with regard to antagonism of rocuronium and other aminosteroid muscle relaxants.