Neonatal outcomes following prophylactic administration of phenylephrine or noradrenaline in women undergoing scheduled caesarean delivery: A randomised clinical trial.

BACKGROUND: There is limited evidence to support the use of noradrenaline over phenylephrine during elective caesarean section with regards to its impact on foetal acidosis. Concerns regarding a deleterious effect of noradrenaline on foetal blood gas analysis because of its ß-mimetic activity cannot currently be ruled out by data from randomised controlled trials. OBJECTIVE: We hypothesised that noradrenaline would be associated with higher umbilical artery base excess values and less foetal acidosis compared with phenylephrine. This study aimed to observe the effect of prophylactic infusions of phenylephrine or noradrenaline in low-risk elective caesarean delivery on umbilical artery blood gas analysis. DESIGN: A prospective, randomised, double-blind trial. SETTING: Labour room operating theatre of tertiary care hospital in Northern India from April 2020 to November 2020. PATIENTS: Full-term, nonlabouring pregnant women, scheduled for elective caesarean delivery under spinal anaesthesia. INTERVENTION: Equipotent prophylactic infusions of either phenylephrine 100 µg min-1 or noradrenaline 5 µg min-1 were administered to maintain maternal SBP between 90 and 110% of baseline using a predefined algorithm. MAIN OUTCOME MEASURE: The primary outcome was umbilical artery base excess in noradrenaline versus the phenylephrine group. The incidence of foetal acidosis defined as umbilical artery base excess less than -6 mmol l-1 was also assessed for noradrenaline versus phenylephrine. RESULTS: Median [IQR] umbilical artery base excess was significantly higher in the noradrenaline group: -5.4 [-6.6 to -4.03] versus -6.95 [-9.02 to -4.53] in the phenylephrine group (P = 0.014). No significant difference in the incidence of foetal acidosis was observed between noradrenaline and phenylephrine groups: 36 versus 54% (P 0.07); difference 18% (95% CI, -1.4 to 35.6%). CONCLUSION: Prophylactic noradrenaline 5 µg min-1 infusion resulted in higher base excess values compared with phenylephrine 100 µg min-1 infusion. A comparable incidence of foetal acidosis was observed in women receiving either noradrenaline or phenylephrine. Maternal bradycardia was more pronounced with phenylephrine while targeting blood pressure goals. CTRI: CTRI/2020/03/023986.

EC50 of sevoflurane for classic laryngeal mask airway insertion in children at different time points: A randomized blind trial.

BACKGROUND AND AIMS: Literature documents EC50 (End-tidal) of sevoflurane for CLMA (Classic Laryngeal Mask airway) insertion between 1.5 and 2% and most of these studies suggest maintaining the required end-tidal sevoflurane concentration for 10-25 minutes before LMA insertion. Waiting for this long interval for blood brain sevoflurane equilibration may not be feasible in children especially during failed ventilation. We aimed to estimate EC50 of sevoflurane for CLMA insertion at equilibration time points of 2.5 min and 5.0 min. MATERIAL AND METHODS: In this randomized trial, children aged 2_8 years of either sex having American Society of Anesthesiologists status I undergoing elective cataract surgery were included. After inhalational induction of general anesthesia with 8% sevoflurane and 100% oxygen, intravenous cannulation was secured. The sevoflurane vaporizer was finely adjusted to maintain an end-tidal sevoflurane concentration at 2% for 2.5 min for first child in group 2.5 and 5 min in group 5.0. This was followed by LMA insertion which was considered to be unsuccessful if there was "movement" and successful if "no movement" occurred. End-tidal concentration was increased/decreased (step-size 0.2%) using Dixon and Massey up and down method in the next patient depending upon the previous patient's response. RESULTS: EC50 of sevoflurane for insertion of classic LMA in children aged 2-8 yrs in 100% oxygen was 1.1% (0.9-1.2) at 2.5 min and 1.6% (1.5-1.7) at 5.0 min. Derived EC95 (95% CI) at 2.5 min was 1.8% (1.5-9.2) and at 5.0 min was 1.8% (1.4-8.8) respectively. CONCLUSION: We suggest maintaining end-tidal sevoflurane of 1.6% for 2.5 min and 1.8% for 5 min for successful CLMA insertion.

Sevoflurane EC50 for intravenous cannulation attempt and movement in children.

BACKGROUND: Intravenous cannulation at lighter planes of anaesthesia can lead to adverse respiratory and haemodynamic events. So far, there is no consensus on optimum end tidal sevoflurane concentration required for intravenous cannulation in children. We aimed to evaluate the optimum end tidal concentration at which an intravenous cannulation can be successfully attempted without movements in paediatric patients after inhalational induction of general anaesthesia. MATERIAL AND METHODS: In this clinical trial, paediatric subjects of either sex aged 1-3 years, weighing 7-15 kg having American Society of Anaesthesiologists physical status I/II of undergoing elective cataract surgery were included. After inhalational induction of general anaesthesia with 8% sevoflurane and 100% oxygen, end tidal sevoflurane concentration was maintained at 2% for 4 minutes for the first child. This was followed by intravenous cannulation attempted by an experienced anesthesiologist. The intravenous cannulation was considered to be unsuccessful if there was "movement" and successful if there was "no movement" in response to the stimuli of cannulation. End-tidal concentration was increased/decreased (step-size 0.2% for sevoflurane) using Dixon and Massey up and down method in the next patient depending upon previous patient's response. RESULTS: The sevoflurane EC50 for successful intravenous cannulation is 1.32% ± 1.0%. Pearson correlation (r) between weight of the child and response to intravenous cannulation was found to be 0.40 with P value of 0.008. CONCLUSION: Intravenous cannulation can be accomplished without movements at end tidal sevoflurane of 1.3% in children aged 1-3 years in 50% of children.

Effective concentration (EC50) of sevoflurane for intraocular pressure measurement in anaesthetised children with glaucoma: A dose-finding study.

Background and Aim: Sevoflurane, a preferred anaesthetic for children, exhibits a dose-dependent reduction in intraocular pressure (IOP). However, consensus is lacking regarding optimal end-tidal sevoflurane concentration for safe IOP measurement. This study aimed to identify the concentration at which IOP measurement could be attempted without inducing movements in paediatric patients after inhalational induction. Methods: Two paediatric groups (1-12 months and 12-36 months) with glaucoma undergoing examination under anaesthesia were recruited. After induction with 8% sevoflurane and 100% oxygen, the first child had an end-tidal sevoflurane concentration maintained at 2% for 4 min, followed by IOP measurement. Success was defined as 'no movement', and subsequent concentrations (adjusted in 0.2% steps) were determined using the Dixon and Massey method based on the previous patient's responses. Results: The study included 75 children. The effective concentration of sevoflurane causing 'no movement' during IOP measurement in 50% of the study population for successful IOP measurement was 1.98% (95% confidence interval [CI] 1.63, 2.17, P = 0.017) for 1-12 months group and 0.55% (95% CI 0.39, 0.66, P = 0.002) for 12-36 months group. Probit regression analysis yielded effective concentration of sevoflurane causing 'no movement' during IOP measurement in 95% of the study population values of 2.47% (95% CI 2.24, 4.58, P = 0.017) for 1-12 months group and 0.94% (95% CI 0.78, 1.57, P = 0.002) for 12-36 months group. Conclusion: In paediatric patients, a higher end-tidal sevoflurane concentration of 2% is needed for IOP measurement in 1-12 months age group compared to 0.5% required in 12-36 months age group, achieving success in 50% of the study population.

Effect of prophylactic corticosteroids on postoperative neurocognitive dysfunction in the adult population: An updated systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials.

Background and Aims: Postoperative neurocognitive dysfunction (PNCD) commonly occurs after surgery and prolongs hospital stays. Both direct noxious stimuli to the central nervous system and systemic inflammation have been implicated. Due to their potent anti-inflammatory effects, corticosteroids have been utilised to attenuate the incidence and severity of PNCD. This systematic review and meta-analysis strived to evaluate the prophylactic role of perioperative corticosteroids for PNCD. Methods: A search was run in pre-defined databases for randomised controlled trials (RCTs) assessing the role of corticosteroids in preventing PNCD. The incidence of PNCD within 1 month was the primary outcome. Secondary outcomes included the use of antipsychotic medications for the treatment, postoperative infection, and hospital length of stay. The results are exhibited as odds ratio (OR) and the mean difference (MD) with 95% confidence interval (CI). Results: Fifteen RCTs comprising 15,398 patients were included. The incidence of PNCD was significantly lower in the corticosteroid group than in the control group, with a pooled OR of 0.75 (95% CI 0.58, 0.96; P = 0.02; I2 = 66%). Trial sequential analysis showed the clinical benefit of corticosteroids in preventing PNCD; however, the requisite information size is still inadequate. The sub-group analysis supported the prophylactic effect of corticosteroids on delirium prevention but not on delayed neurocognitive recovery. Conclusions: Our meta-analysis revealed statistically significant protective effects of corticosteroids on the incidence of PNCD. However, further studies are still needed to confirm the protective role of this commonly used and relatively safe strategy for preventing PNCD.

The Role of Trans Oral Robotic Surgery in the Carcinoma of Unknown Primary: A New Evidence in the Horizon?

The detection of the primary site in Carcinoma of Unknown Primary (CUP) is a challenging task which can significantly alter the course of management and also prognosis. Various modalities have been assessed with varying sensitivity and specificity. Imaging and cytological diagnosis have formed a key part of the diagnostic algorithm of CUP. Trans Oral Robotic Surgery offers the advantage of being both diagnostic as well as therapeutic with promising sensitivity and specificity and can form an integral part in the management of CUP. A prospective study was carried out at a tertiary care centre over a period of one year. Patients with unilateral neck swelling which was histopathologically proven squamous cell carcinoma neck metastasis were included in the study. They were evaluated with endoscopy and radiology according to the standard algorithm. When these failed to detect the primary, the patients underwent ipsilateral radical tonsillectomy and tongue base mucosal wedge biopsy via TORS. Post-operative histopathological examination was done on the resected specimens to detect the primary site. Transoral Robotic Surgery was able to localise primary in 50% of the patients enrolled in the study. Out of the primary site identified by TORS; 55.56% were located in the tonsil and 44.4% in the tongue base. TORS can offer promising detection rates of the occult primary in CUP and should form an integral part of the diagnostic algorithm.

Evaluation and optimization of downstream process parameters for extraction of betulinic acid from the bark of Ziziphus jujubae L.

Present work investigated an apposite and efficient method for extraction of betulinic acid (BA) from the bark of Ziziphus jujubae. Various extraction methods like stirring extraction, soxhlet extraction, ultrasonic extraction, and microwave assisted extraction (MAE) were evaluated for increasing recovery percentage of BA. From the raffinate so obtained, BA was isolated. Thin layer chromatography (TLC) was used to analyze the extract and high performance liquid chromatography (HPLC) for quantification. The results revealed that the percentage extraction of BA from Z. jujubae by MAE was more proficient. As recovery percentage of BA by MAE technique turned out to be maximum, by using response surface methodology (RSM), three process parameters (pH, temperature, and time) were optimized by MAE and it was observed that the optimum parameters (pH 6.5, temp. 70.23°C, and time 3.5 min) gave the maximum recovery of BA (0.44% w/w). To validate the RSM model, experiments were performed and the highest recovery of BA was found to be 0.4% w/w which is ±0.04% to the predicted value. Henceforth the extraction efficiency and the substantial saving of time by MAE was more capable than the other extraction techniques.

A Preliminary Feasibility Study on Hemodynamic Changes Following Feyh-Kastenbauer Retractor Insertion During Transoral Robotic Surgeries.

 Introduction Transoral robotic surgery (TORS) has become increasingly popular for the removal of pharyngeal and laryngeal cancers with the objective to improve functional and aesthetic outcomes. Feyh-Kastenbauer (FK) retractor is one such routinely used retractor during TORS. The setting up of this retractor has been seen to be accompanied by hemodynamic fluctuations. Methodology This prospective observational study was carried out on 30 patients undergoing TORS. All patients were administered general anesthesia using a pre-defined anesthesia protocol. The primary outcome was to compare hemodynamic fluctuations following endotracheal intubation with that after FK retractor insertion. Any requirement of a bolus dose of sevoflurane and fentanyl was recorded in response to hemodynamic fluctuations recorded in secondary outcomes. Results There was no statistically significant increase in mean heart rate, systolic, diastolic, and mean arterial blood pressure from baseline to endotracheal intubation and following retractor insertion (p=0.810, p=0.2, p=0.6, p=0.3 respectively). On subgroup analysis, hypertensive patients reported a greater rise in blood pressure following two minutes post FK retractor insertion compared to non-hypertensive patients (p=0.03). Out of 30 patients, five patients required a bolus dose of sevoflurane. Conclusion FK retractor insertion had a comparable hemodynamic response as endotracheal intubation during TORS. Hypertensive patients showed a rise in blood pressure at both endotracheal intubations and at FK retractor insertion.

Lung ultrasonography as a tool to guide perioperative atelectasis treatment bundle in head and neck cancer patients undergoing free flap reconstructive surgeries: a preliminary observational study.

INTRODUCTION: General anesthesia causes pulmonary atelectasis within few minutes of induction. This can have significant impact on postoperative outcome of cancer patients undergoing prolonged reconstructive surgeries. OBJECTIVE: The purpose of this study was to evaluate the impact of sonographically detected perioperative atelectasis on the need for postoperative oxygen supplementation, bronchodilator therapy and assisted chest physiotherapy in patients undergoing free flap surgeries for head and neck carcinoma. METHODS: Twenty eight head and neck cancer patients underwent bilateral pulmonary ultrasonographic assessments before and after lung surgery. Lung ultrasound scores, serum lactate, and PaO2/FiO2 ratio were measured both at the beginning and at end of the surgery. Patients were scanned in the supine position and the number of single and confluent B lines was noted. These values were correlated with the need for oxygen therapy, requirement of bronchodilators and total weaning time to predict the postoperative outcome. Other factors affecting weaning were also studied. RESULTS: Among twenty eight patients, seven had mean lung ultrasound score of ≥10.5 which correlated with prolonged weaning time (144.56±33.5min vs. 66.7±15.7min; p=0.005). The change in lung ultrasound score significantly correlated with change in PaO2/FiO2 ratio (r=-0.56, p=0.03). Elevated total leukocyte count >8200µL and serum lactate >2.1mmoL/L also predicted prolonged postoperative mechanical ventilation. CONCLUSION: This preliminary study detected significant levels of perioperative atelectasis using point of care lung ultrasonography in head and neck cancer patients undergoing long duration surgical reconstructions. Higher lung ultrasound scores highlighted the need for frequent bronchodilator nebulizations as well as assisted chest physiotherapy and were associated with delayed weaning. We propose more frequent point of care lung ultrasonographic evaluations and use of recruitment maneuvers to reduce the impact of perioperative pulmonary atelectasis.

Effect of Orogastric Acetazolamide on Optic Nerve Sheath Diameter in Patients Undergoing Laparoscopic Donor Nephrectomies: A Randomized, Double-Blind Trial.

Introduction Laparoscopic Live Donor Nephrectomy(LLDN) is becoming an increasingly frequent procedure. The rise in intracranial pressure(ICP) during LLDN has not been measured yet. ICP can be evaluated by measuring ultrasonographic optic nerve sheath diameter(ONSD). Acetazolamide has been found to provide effective analgesia following LLDN. It also helps lowering the raised ICP. Therefore, we planned to study effect of orogastric Acetazolamide on ONSD in patients undergoing LLDN. Methods Forty Donors scheduled for LLDN were randomized preoperatively either into Group A receiving acetazolamide 5mg/kg or Group S receiving normal saline. ONSD was measured at time points:Time 0: In supine position before induction of GA, Time 1: 5 minutes after induction of GA but before giving orogastric acetazolamide, Time 2: 10 minutes after creating pneumoperitoneum, Time 3: 60 minutes after creating pneumoperitoneum, Time 4: Towards end of surgery, just before taking out specimen in modified flank position, Time 5: after extubating in supine position. Results Mean ONSD of left eye(4.42 ± 0.48) in Group S was significantly more than mean ONSD of left eye(4.16 ± 0.15; p-0.036) in Group A at 10 mins after creating pneumoperitoneum in modified flank position. Mean ONSD showed significant increase in group S at 10 and 60 minutes(4.374 ± 0.433mm in group S vs 4.151 ± 0.168 in group A; p-0.042 at 10 mins and 4.336 ± 0.301mm in group S vs 4.149 ± 0.282mm in group A; p-0.050 at 60 mins) after creating pneumoperitoneum as compared to group A. Conclusion Orogastric acetazolamide 5 mg/kg was found to be beneficial in preventing rise in ONSD from 10 minutes to 1 hour of creating pneumoperitoneum in patients undergoing laparoscopic donor nephrectomy under general anaesthesia. Acetazolamide was also found to be effective in reducing postoperative pain.

Analysis of Outcomes following TORS in a Mixed Cohort of Recurrent and New T1-T2 Oropharyngeal Cancer- A Single Institution Study.

Purpose: . The transoral robotic surgery is a newer modality being used in surgical treatment of early oropharyngeal cancer. The aim of this study is to assess the outcome of these cases in terms of two year disease free survival and overall survival. Methods: Between July 2016 and September 2018, 58 patients suffering from early oropharyngeal cancer underwent transoral robotic surgery with neck dissection at a tertiary referral centre. 43 of them have completed two years follow up and were analyzed for disease free survival and overall survival. 41 patients had HPV analysis done . Results: The surgical margins were positive in 9/43 patients ( 6 in upfront surgery and 3 in the salvage cohort). Adjuvant therapy was administered to 16/34 patients on account of either positive margins or multiple nodal metastasis. 88% patients were found to be HPV negative. The two year disease free survival for the upfront cohort was 88.2% and salvage cohort was 55.5%. The overall survival was 86.05%. Conclusions: The study highlights good locoregional control and two year disease free survival in HPV negative oropharyngeal cancer undergoing robotic surgery. Additionally, a positive surgical margin and recurrence were the statistically significant variables influencing 2 year disease free survival. Trans oral robotic surgery is an excellent tool for early tumors of the oropharynx. The presence of a positive surgical margin is a grim sign for survival and has a significant impact on positive outcome. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03139-5.

Paravertebral block using levobupivacaine or dexmedetomidine-levobupivacaine for analgesia after cholecystectomy: a randomized double-blind trial.

BACKGROUND: Thoracic paravertebral block (TPVB) has emerged as an effective and feasible mode of providing analgesia in laparoscopic cholecystectomy. Though a variety of local anaesthetic combinations are used for providing TPVB, literature is sparse on use of dexmedetomidine in TPVB. We aimed to compare levobupivacaine and levobupivacaine-dexmedetomidine combination in ultrasound guided TPVB in patients undergoing laparoscopic cholecystectomy. METHODOLOGY: 70 ASA I/II patients, aged 18-60 years, scheduled to undergo laparoscopic cholecystectomy under general anaesthesia were enrolled and divided into two groups. Before anaesthesia induction, group A patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml normal saline while group B patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml solution containing dexmedetomidine 1 µg.kg-1. Patients were monitored for pain using Numeric Rating Scale (NRS) at rest, on movement, coughing and comfort scores post surgery. Total analgesic consumption in first 48 hour postoperative period, time to first request analgesic and pain scores were recorded. RESULTS: Total amount of rescue analgesia (injection tramadol plus injection tramadol intravenous equivalent dose) consumed during 48 hours postoperatively in group A was 146.55 mg while in group B was 111.30 mg (p = 0.026). Mean time for demanding rescue analgesia was 273 minutes in group A while in group B was 340 minutes (p = 0.00). CONCLUSION: TPVB using dexmedetomidine 1 µg.kg-1 added to levobupivacaine 0.25% in patients undergoing laparoscopic cholecystectomy significantly reduced total analgesic consumption in first 48 hours and provided longer duration of analgesia postoperatively compared to levobupivacaine 0.25% alone.

Ropivacaine induced systemic toxicity in a patient with phacomatosis pigmentokeratotica.

Calculation of the maximum recommended dose of local anesthetic minimizes the risk of Local Anesthetic Systemic Toxicity (LAST) when administrating multiple blocks for lower limb surgeries. Ropivacaine is the preferred local anesthetic as it is less lipophilic than bupivacaine and thus results in less central nervous system (CNS) and cardiovascular toxicity. The presence of developmental, congenital, and metabolic disorders mandates an extracautious approach in the administration of large volume of Local anaesthesia (LA) as the vascularity of the limb, levels of alpha-1-acid glycoprotein, and sensitivity of the sodium channels may be altered. This case report highlights successful resuscitation of a patient with Phacomatosis pigmentokeratotica after the development of CNS toxicity secondary to the administration of ropivacaine in ultrasound-guided combined lumbar plexus and sciatic nerve block. We identified some high risk patient profiles which should be vigilantly monitored to minimize the incidence of LAST.

Thoracoabdominal Aortic Aneurysm Repair: What Should the Anaesthetist Know?

The surgical repair of descending thoracic aortic (DTA) and thoracoabdominal aortic aneurysms (TAAAs) presents one of the greatest challenges for anaesthesiologists. The challenge comes from the fine balance of complex medical issues in the setting of altered physiology that occurs during the perioperative period. Patients presenting for TAAA repair usually have multiple pre-existing comorbid conditions involving their cardiac, pulmonary and renal systems; and aneurysm repair poses a direct and immediate threat to these systems in addition to that to the gastrointestinal and neurologic systems. Operative mortality in thoracoabdominal aortic surgery is quite high to the extent of 5%-12% with a 5-year survival rate of 70%-79% for DTA aneurysm and 59% for thoracoabdominal aortic aneurysm surgeries. Complex haemodynamic changes associated with the clamping and declamping of aorta requires thorough knowledge and expertise for the management of TAAA. We present a brief review on the anaesthetic management and possible complications that anaesthetists should be aware of during TAAA repair.