Intravenous Dexmedetomidine-Ketamine Versus Ketamine-Propofol for Procedural Sedation in Adults Undergoing Short Surgical Procedures: A Randomized Controlled Trial.

Background and objective Moderate to deep sedation is a prerequisite during total intravenous anesthesia for short-duration surgeries, and it can be achieved by using individual drugs or in combination. Our study compared dexmedetomidine-ketamine (DK) versus ketamine-propofol (KP) in terms of sedation, procedural interference, hemodynamics, and incidence of side effects in patients undergoing short surgical procedures. Methods A total of 194 patients scheduled for short-duration elective surgeries were randomly allocated into two groups. Group DK received a loading dose of 1 µg/kg of dexmedetomidine and 1 mg/kg of ketamine followed by a maintenance infusion of dexmedetomidine at 0.3 µg/kg/h. Group KP received a loading dose of 1 mg/kg of ketamine and 1 mg/kg of propofol followed by a maintenance infusion of propofol at 25 µg/kg/h. For procedural interference, a rescue ketamine bolus was administered at 0.25 mg/kg. Patients were monitored for the requirement of rescue ketamine bolus, procedural interference, hemodynamics, sedation, recovery time, and adverse effects. Results The procedural interference was higher in group KP than in group DK and the difference was statistically significant (P=0.001). The time to the first rescue bolus was 8.72 ± 4.47 minutes in group KP and 10.82 ± 4.01 minutes in group DK, with a difference of 2.1 minutes (p=0.026). There was no statistically significant difference in the sedation scores between both groups except at time points of six minutes and 15 minutes. Conclusion For short-duration procedures, the DK combination is superior to the KP combination in terms of procedural interference and time to the first rescue bolus, while both groups were comparable with regard to safety and hemodynamics.

Effectiveness of Anti-Mullerian Hormone-tailored Protocol Compared to Conventional Protocol in Women Undergoing In vitro Fertilization: A Randomized Controlled Trial.

BACKGROUND: Assessment of ovarian reserve before an in vitro fertilization cycle (IVF) is one among the many factors that predicts a successful cycle. Individualized protocol based on ovarian reserve is designed to optimize the pregnancy outcome without compromising the patient safety. Although authors have shown that anti-Mullerian hormone-tailored (AMH) protocols have reduced the treatment burden and improved pregnancy rates, a few others have questioned its efficacy. AIMS: The aim of this study was to decide whether the AMH-tailored protocol or the conventional protocol better decides IVF outcomes. SETTING AND DESIGN: Prospective randomized controlled trial conducted at a tertiary level university hospital. MATERIALS AND METHODS: Patients undergoing theirfirst IVF cycle who fulfilled the inclusion criteria were recruited and randomized to each group. Serum follicle-stimulating hormone was done for the patients on day 2 or 3 of a prior menstrual cycle, and serum AMH was done in the preceding cycle. STATISTICAL ANALYSIS: Analysis was performed using SPSS software version 16. RESULTS AND CONCLUSION: There were 100 patients in each group. A total of 83 patients underwent embryo transfer in the conventional group and 78 patients in the AMH group. The clinical pregnancy rates per initiated cycle (36.4% vs. 33.3%) and per embryo transfer (45.1% vs. 41.3%) were similar in both the groups. There was no statistical difference in the number of cycles cancelled due to poor response or the risk of ovarian hyperstimulation syndrome in both the groups. Hence, this study showed the similar effectiveness of AMH-tailored protocol and conventional protocol in women undergoing IVF.

Local endometrial injury in women with failed IVF undergoing a repeat cycle: A randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of local endometrial injury in women undergoing in vitro fertilization (IVF) with at least one previous unsuccessful attempt. STUDY DESIGN: Randomized controlled trial. Recruited women were randomized into two groups. In group A (pipelle group), women underwent pipelle biopsy twice in the luteal phase in the cycle prior to IVF. In group B (control), women did not undergo any intervention prior to IVF. The primary outcome was clinical pregnancy rate. The secondary outcomes included live birth, miscarriage, multiple pregnancy and preterm delivery rates. RESULTS: One hundred and eleven women were included in the study with 55 in the pipelle group and 56 in the control arm. The baseline clinical characteristics were similar in both groups. The clinical pregnancy rates were not significantly different between pipelle and control group (34.09% vs. 27.65%; Odds ratio, OR 1.35, 95% confidence interval, CI 0.55-3.30). The live birth (31.81% vs. 25.53%; OR 1.36, 95% CI 0.55-3.39), multiple pregnancy (33.33% vs. 61.54%; OR 0.31, 95% CI 0.07-1.47), miscarriage (6.66% vs. 7.69%; OR 0.86, 95% CI 0.05-15.23) and preterm delivery rates (35.71% vs. 66.66%; OR 0.28, 95% CI 0.05-1.4) were also not significantly different between the two groups. CONCLUSION: Current study did not find any improvement in IVF success rates following endometrial injury in woman undergoing IVF after previous failed attempt.

Spontaneous puerperal extraperitoneal bladder wall rupture in young woman with diagnostic dilemma.

A young female presented with an acute abdominal pain and oliguria for 1 week following normal vaginal delivery. No history of hematuria was present. Patient was having lochia rubra. Sealed uterine rupture was suspected clinically. Initial ultrasound of the patient showed distended urinary bladder containing Foley catheter ballon with clamping of Foley catheter and particulate ascites. Abdominal paracentesis revealed hemorrhagic fluid. Contrast-enhanced computed tomography of abdomen revealed ascites, distended urinary bladder and no extraluminal contrast extravasation in delayed scan. As patient condition deteriorated, repeat ultrasound guided abdominal paracentesis was done which revealed transudative peritoneal collection with distended bladder. Cystoscopy revealed urinary bladder ruptures with exudate sealing the rupture site. Exploratory laparotomy was done and a diagnosis of extraperitoneal bladder rupture was confirmed. The rent was repaired in layers. She was put on continuous bladder drainage for 3 weeks followed by bladder training. It presented in a unique way as there was hemorrhagic peritoneal tap, no macroscopic hematuria and urinary bladder was distended in spite of urinary bladder wall rupture which delayed the diagnosis and treatment. Complete emptying of urinary bladder before second stage of labor and during postpartum period with perineal repair is mandatory to prevent urinary bladder rupture.