Effect of propofol titration v/s bolus during induction of anesthesia on hemodynamics and bispectral index.

BACKGROUND: Propofol when given as 2 mg/kg IV bolus for induction of anesthesia is known to cause hypotension requiring vasopressors. The objective of our study was to compare Propofol 2 mg/kg single IV bolus (Precalculated group, PG) with the titration of Propofol (Titration group, TG) to clinical parameters as 10 mg IV increments every 3 seconds on hemodynamic Parameters and Bispectral Index (BIS), during induction. The effect of titration on dose requirement for induction was also evaluated. METHODS: Effects on Hemodynamic parameters [Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP)], and vasopressors use were recorded at baseline and every 2 minute intervals for 10 minutes. The percent difference in HR, SBP, DBP, and MAP from baseline at 2, 4, 6, 8 and 10 minutes were calculated, to determine the effect on hemodynamic parameters. BIS was recorded at baseline, after injection of Propofol, at intubation and at 10 minutes. Dose requirement of Propofol in TG was also recorded. RESULTS: At 2 and 4 minutes, SBP decreased in PG by 21% and 18% vs. 11% and 9% in TG (p = .00 & .02); DBP decreased by 17% and 15% in PG vs. 5% and 4% in TG (p = .02 & .03); MAP decreased by 19% and 17% in PG vs. 5% and 4% in TG (p = .00 & .01). Vasopressors were required in 14/43 patients in PG vs. 5/41 in TG (p = .03). Titration resulted in 30% reduction in dose. CONCLUSION: Titration of Propofol reduces hemodynamic changes, dose requirement and is able to achieve same level of BIS as in bolus.

Lymphopenia and Severe Combined Immunodeficiency (SCID) - Think Before You Ink.

OBJECTIVES: Severe combined immunodeficiency (SCID) represents one of the most severe forms of Primary immunodeficiency (PID) disorders, characterized by T cell lymphopenia (TCL) and lack of cellular and humoral immune responses. However, not all patients with low T cell lymphocyte counts may have an abnormal T cell immunity and the observed TCL may be a temporary suppression resulting from transient lymphopenia secondary to severe infections. In such cases, it is necessary to estimate the severity of the observed TCL by assessing thymic capabilities. METHODS: In this study, patients clinically suspected of SCID were evaluated for lymphocyte subsets analysis, naïve T cells and T cell receptor excision circles (TREC). RESULTS: Patients with transient lymphopenia had detectable TREC levels and normal naïve T cells subsets. Normalization of absolute lymphocyte counts, and T cells was seen in the patients after a short duration. CONCLUSIONS: The authors highlight the importance of detailed immunological investigations in an infant with severe infections and lymphopenia before labeling the infant as SCID.

Carbon dioxide absorber as a cause of high airway pressures.

We investigate an incident in which a carbon dioxide absorber caused difficulty with ventilation. The problem as it developed throughout the anesthetic, and clues that led to the determination that the carbon dioxide canister was the problem, is discussed.

The use of a laryngeal mask airway after a prolonged suspension laryngoscopy to preserve a vocal cord fat graft.

A 62-yr-old man presented for a microdirect laryngoscopy and vocal cord fat grafting under jet ventilation. After a prolonged laryngoscopy, the patient developed hypercapnea and upper airway obstruction secondary to traumatic epiglottitis. The placement of a laryngeal mask airway provided ventilation and allowed for direct visualization of the patient's inflamed epiglottis without disruption of the patient's fat graft. Because of its placement above the cords and its effectiveness in providing adequate ventilation, we propose intermittent laryngeal mask airway ventilation as a bridge, in lieu of endotracheal intubation, in microdirect laryngoscopy cases in which ventilation during emergence may be difficult and the insertion of an endotracheal tube would disrupt the surgical procedure.

H. influenzae type b (Hib) vaccine--controversies.

Hib vaccine is the 8th vaccine knocking at the door to be included in the EPI the world over. However there are some controversies that need to be addressed, especially when it comes to use of this vaccine in India. It is difficult to culture Hib unless one uses sheep blood enriched media for culture. There is a lack of good community based data on Hib burden in India. This makes many feel that Hib is rare in India. However this is not true. There are many studies that have looked at this closely. Hib is a common cause of meningitis and pneumonitis in children less than 5 years old in India. There is wide spread problem of multi-drug resistance by Hib in India. Mortality of meningitis is as high as 100% if third generation cephalosporins are not used in time. Of the survivors of meningitis, 60% develop long-term sequelae. Hib vaccine is very effective and can lead to 99% reduction with mass vaccination in just 2-3 years. It is also a very safe vaccine. Of the conjugated vaccines available in India all are equally effective and safe and there is nothing to choose one over the other. There is a need to give a booster dose at 15-18 months of age. Even UK, which never gave the booster dose, is seriously thinking of changing their practice and give a booster dose. Lastly the combination vaccines of Hib with IPV, DPwT/DPaT, and Hepatitis B are safe and effective and should be encouraged to improve the compliance. The use of Hib vaccine is recommended in India, for those who can afford the vaccine.

Summary of invasive pneumococcal disease burden among children in the Asia-Pacific region.

Invasive pneumococcal disease (IPD) burden is significant in the Asia-Pacific region. This review describes the epidemiology and Streptococcus pneumoniae (SP) serotype distribution of IPD in children in the Asia-Pacific region from studies published from 1999 to 2010. IPD incidence varies widely in Asia-Pacific countries depending on the method of surveillance, the population studied, and the time period. Incidences are highest for younger children, with rates near 100-200 cases per 100,000 children aged <1 or 2 years. Incidences of preventable disease are estimated to be 6-200 cases per 100,000. Heptavalent pneumococcal conjugate vaccine (PCV7) serotype coverage shows a very wide range over the Asia-Pacific region. Ten countries have high vaccine serotype coverage (>70%), and six countries have low vaccine serotype coverage (<50%). The majority of SP serotypes in children with IPD in most countries in the Asia-Pacific region are susceptible to penicillin (intermediate and resistant <50%); a few countries have SP serotypes with high level resistance to penicillin (intermediate and resistant >50%). Japan, Taiwan, and Thailand have high PCV7 serotype coverage. Countries with low pneumococcal resistance to antimicrobials have shown increasingly higher nonsusceptibility with time. National vaccination programmes that include PCV7, 10-valent pneumococcal conjugate vaccine (PCV), or 13-valent PCV would significantly affect IPD burden in children aged <5 years in the Asia-Pacific region, as well as the burden of penicillin-nonsusceptible IPD.

Adolescent vaccination.

Indian Academy of Pediatrics (IAP) has taken an important step towards adolescent vaccination. In the present article, the author has briefly described the needs for adolescent immunisation along with the IAP vaccination schedule for adolescents, in details.