Advantages of 1-1-12 Wash in Scheme during Induction with Low Flow Anesthesia with and without Nitrous Oxide.

INTRODUCTION: In the past, many wash-in schemes have been used with initially high fresh gas flow (FGF) to achieve the necessary alveolar concentration of inhalational agent in 10-15 min. This study was designed to show whether 1-1-12 wash-in scheme proposes an earlier achievement of induction or is there any requirement of high FGF phase to know the time taken for induction with and without nitrous oxide (N2O). AIMS: The aim of the study was to find out the time required for the alveolar concentration of desflurane to be from 1% to 6% with and without N2O. DESIGN: It was a potential randomized study which was conducted on sixty patients admitted for elective surgery. MATERIALS AND METHODS: Two groups of thirty patients each were made and randomly assigned. Group N received desflurane with N2O plus oxygen and Group A received desflurane with air plus oxygen. STATISTICAL ANALYSIS: The observations were noted and evaluated accordingly. Analysis was done using unpaired t-test. RESULTS: Hemodynamic parameters were almost similar in both the groups. In Group N, gradual FAD (Alveolar Desflurane concentration, i.e., end-tidal desflurane) from 1% to 6% was achieved at 0.5, 1, 1.5, 2, 3, and 4 min. In Group A, the same was achieved at 0.6, 1, 1.5, 2, 3, and 4 min (P > 0.05). No significant difference was found between the recuperation time and score in both the groups. Rather complications were more in Group N and statistically significant for nausea and vomiting. CONCLUSION: Time taken to attain FAD from 1% to 6% was 4 min in both the groups. It is concluded that the recitation of 1-1-12 wash-in scheme is autonomous on the use of N2O and high FGF phase.

Impact of different intravenous fluids on blood glucose levels in nondiabetic patients undergoing elective major noncardiac surgeries.

BACKGROUND: Intravenous (IV) fluids are an integral part of perioperative management. Intraoperative hyperglycemia is associated with poor clinical outcomes in patients undergoing major surgeries even in nondiabetics. AIM: This study was conducted to observe the effect of different maintenance fluid regimens on intraoperative blood glucose levels in nondiabetic patients undergoing major surgeries under general anesthesia. SETTINGS AND DESIGN: Randomized double-blind study. MATERIALS AND METHODS: One hundred nondiabetic patients of either sex were divided randomly into two Groups I and II of 50 each undergoing elective major surgeries of more than 90 min duration under general anesthesia. Both groups were given calculated dosage of IV fluids accordingly 4-2-1 formula while Group I was given Ringer lactate (RL) and Group II was given 0.45% dextrose normal saline and potassium chloride 20 mmol/L. Changes in vital parameters, % oxygen saturation, and urine output were monitored at regular intervals. Capillary blood glucose (CBG) was measured half-hourly until end of surgery. If CBG level was more than 150 mg%, then calculated dose of human insulin (CBG/100) was given as IV bolus dose. STATISTICAL ANALYSIS: Statistical analysis was done using SPSS 22.0 software (IBM Corporation, Armonk, New York, USA), paired t-test and Chi-square test. RESULTS: A significant increase of CBG level and was observed during intraoperative and immediate postoperative period (P < 0.001) in Group II. CONCLUSION: RL solution is probably the alternative choice of IV fluid for perioperative maintenance and can be used as replacement fluid in nondiabetic patients undergoing major surgeries.

Gabapentin vs pregabalin as a premedication in lower limb orthopaedics surgery under combined spinal epidural technique.

BACKGROUND: Pregabalin and gabapentin are the gamma-aminobutyric acid analogs used as a part of multimodal analgesic regimen. AIM: To compare the postoperative analgesic benefits of gabapentin or pregabalin as a premedication for lower limb orthopedic surgery under combined spinal-epidural techniques. SETTINGS AND DESIGN: Randomized double-blind study. MATERIALS AND METHODS: A total of 90 patients were divided into three groups: G, P, C who received gabapentin 1200 mg, pregabalin 300 mg, and placebo, respectively 1.5 h before surgery. All patients received combined spinal-epidural block with 3 ml of 0.5% intrathecal bupivacaine. Assessment of pain was made with visual analog scale (VAS). Postoperative analgesia was provided with epidural top-ups with 2.5 ml of 0.5% bupivacaine and fentanyl 25 µg when VAS >3. Rescue analgesia in the form of injection diclofenac (75 mg) intramuscularly was given if VAS >3 even after epidural top-up. A total number of epidural top-ups, rescue analgesia, pain-free interval postspinal anesthesia, and sedation score were noted. STATISTICAL ANALYSIS: This was done using SPSS version 17. Mean and standard deviation were calculated using Chi-square test and analysis of variance. RESULTS: The total postoperative analgesic time was 7.23 h in Group G, 14.80 h in Group P, and 4.17 h in Group C. A total number of epidural top-ups were 2.43 in Group G, 0.77 in Group P, and 4.43 in Group C. CONCLUSION: Pregabalin 300 mg and gabapentin 1200 mg significantly reduce the need of postoperative rescue analgesia, epidural top-ups, and increase the duration of postspinal anesthesia without altering hemodynamics with sedation as a major side effect.

Sevoflurane in low-flow anesthesia using "equilibration point".

CONTEXT: While giving low-flow anesthesia, it is a routine practice to give fixed duration of initial high-flow. This study was conducted to show the use of equilibration point as changeover point from initial high-flow to low-flow. AIMS: It was to compare the use of equilibration point, hemodynamics, end-tidal agent concentration, recovery time, and recovery score between isoflurane and sevoflurane. SETTINGS AND DESIGN: It was a prospective randomized study conducted on 100 patients who were admitted for elective surgery expected to be < 2 h duration. MATERIALS AND METHODS: Patients were randomly assigned to one of the two groups of 50 each. Group I received isoflurane and Group S sevoflurane as an inhalational agent. STATISTICAL ANALYSIS: The observations obtained in both the groups were recorded and compared. Analysis was done using unpaired t-test and Chi-square test. RESULTS: Hemodynamic parameters were comparable in both the groups. The mean equilibration times obtained for sevoflurane and isoflurane were 8.22 ± 1.060 min and 17.24 ± 10.2 min, respectively. The drift in end-tidal agent concentration over time was less in sevoflurane group. Mean recovery time was 7.92 ± 1.56 min in the sevoflurane group and 12.89 ± 3.45 min in the isoflurane group (P = 0.001). There was no significant difference between intraoperative and postoperative complications. CONCLUSION: Use of equilibration time of the volatile anesthetic agent as a changeover point, from high-flow to low-flow, can help us to use circle system with low-flow anesthesia in a more efficient way, especially with newer anesthetics such as sevoflurane.

Epidural nalbuphine for postoperative analgesia in orthopedic surgery.

BACKGROUND: The challenging task of postoperative pain relief comes within the realm of the anesthesiologist. Combined spinal epidural (CSE) anesthesia can be used as the sole technique for carrying out surgical procedures and managing postoperative pain using various drug regimes. Epidural administration of opioids in combination with local anesthetic agents in low dose offers new dimensions in the management of postoperative pain. AIMS: Comparative evaluation of bupivacaine hydrochloride with nalbuphine versus bupivacaine with tramadol for postoperative analgesia in lower limb orthopedic surgeries under CSE anesthesia to know the quality of analgesia, incidence of side effects, surgical outcome and level of patient satisfaction. SETTINGS AND DESIGN: A prospective, randomized and double-blind study was conducted involving 80 patients of American Society of Anesthesiologists physical status I and II coming for elective lower limb orthopedic surgeries carried under spinal anesthesia. MATERIALS AND METHODS: Anesthesia was given with 0.5% of 2.5 ml bupivacaine intrathecally in both the groups. Epidurally 0.25% bupivacaine along with 10 mg nalbuphine (group A) or tramadol 100 mg (group B) diluted to 2 ml to make a total volume of 10 ml was administered at sensory regression to T10. STATISTICAL ANALYSIS: The data were collected, compiled and statistically analyzed with the help of MS Excel, EPI Info 6 and SPSS to draw the relative conclusions. RESULTS AND CONCLUSIONS: The mean duration of analgesia in group A was 380 ± 11.49 min and in group B was 380 ± 9.8 min. The mean sedation score was found to be more in group B than group A. The mean patient satisfaction score in group A was 4.40 ± 0.871 and in group B was 3.90 ± 1.150 which was found to be statistically significant (P < 0.05). We concluded that the addition of nalbuphine with bupivacaine was effective for postoperative analgesia in terms of quality of analgesia and patient satisfaction score as compared to tramadol.

Dilated cardiomyopathy: an anaesthetic challenge.

Idiopathic dilated cardiomyopathy is a primary myocardial disease of unknown etiology characterized by left ventricular or biventricular dilation and impaired contractility. Depending upon diagnostic criteria used, the reported annual incidence varies between 5 and 8 cases per 100,000 populations. Dilated cardiomyopathy is defined by presence of: a) fractional myocardial shortening less than 25% (>2SD) and/or ejection fraction less than 45% (>2SD) and b) Left Ventricular End Diastolic Diameter (LVEDD) greater than 117% excluding any known cause of myocardial disease. Such cases are always a challenge to the anesthesiologist as they are most commonly complicated by progressive cardiac failure. We report the anesthetic management of a patient with dilated cardiomyopathy undergoing surgery for carcinoma breast.

Evaluation of spinal and epidural anaesthesia for day care surgery in lower limb and inguinoscrotal region.

BACKGROUND: Day care surgery is still in its infancy in India. Both regional and general anaesthesia can be used for this. Central neuraxial blocks are simple cheap and easy to perform. This study was done to evaluate usefulness of spinal and epidural anaesthesia for day care surgery. PATIENTS #ENTITYSTARTX00026; METHOD: 100 patients were randomized to either spinal (n=50) or epidural (n=50) group anaesthetized with either 0.5% hyperbaric 2ml bupivacaine or 0.5% 20ml bupivacaine respectively. In spinal group 27 gauze quincke needle and in epidural group 18 gazue tuohy needle was used. Both the groups were compared for haemodynamic stability, side effects, complications, postanaesthesia discharge score (PADS), time taken to micturate, total duration of stay in hospital and patient satisfaction score for technique. RESULTS: We observed that spinal anaesthesia had significantly early onset of anaesthesia and better muscle relaxation (p<0.05) as compared to epidural block otherwise both groups were comparable for haemodynamic stability, side effects or complications. Although more patients in spinal group (64% vs 48%) achieved PADS earlier (in 4-8 hours) but statistically it was insignificant. Time to micturition (6.02 0.55 v/s 6.03 0.47 hours) and total duration of stay (7.49 1.36 v/s 8.03 1.33 hours) were comparable in both the groups. CONCLUSION: Both spinal and epidural anaesthesia can be used for day care surgery. Spinal anaesthesia with 27 gauze quincke needle and 2ml 0.5% hyperbaric bupivacaine provides added advantage of early onset and complete relaxation.