Prophylactic dexamethasone for postoperative nausea and vomiting in pediatric strabismus surgery: a dose ranging and safety evaluation study.

In this double-blind, randomized, placebo-controlled study, we evaluated the efficacy and safety of different doses of prophylactic IV dexamethasone for postoperative nausea and vomiting (PONV) in 168 children (aged 2-15 yr) scheduled for strabismus surgery. Patients received IV dexamethasone 0.25 mg/kg (D 0.25), 0.5 mg/kg (D 0.5), 1.0 mg/kg (D 1), or saline (S) immediately after induction of general anesthesia. Patients were discharged 24 h after surgery. Nausea and vomiting were assessed at 0-2, 2-6, and 6-24 h after surgery. Blood glucose was measured preoperatively and at 4 h after study drug administration. Wound healing and infection were assessed after 1 wk. More patients in group S had vomiting at 0-2, 2-6, and 6-24 h (P = 0.001, P = 0.003, and P = 0.04, respectively) and required larger doses of rescue antiemetics compared with the dexamethasone groups. Fewer patients in the dexamethasone groups (6, 3, and 6 in D 0.25, D 0.5, and D 1, respectively) had severe PONV compared with group S (P = 0.001). No significant increase in postoperative blood glucose levels was observed and wound healing was satisfactory in all four groups. The results suggest that dexamethasone 0.25 mg/kg is more effective than saline and equally effective compared with larger doses for preventing PONV for pediatric strabismus surgery.

Efficacy of low-dose dexamethasone for preventing postoperative nausea and vomiting following strabismus repair in children.

We studied the efficacy of a range of doses of dexamethasone for prevention of postoperative nausea and vomiting following strabismus repair in children in a hospital-based, prospective, double-blinded, randomized, placebo-controlled trial. Two hundred and ten children were randomized to receive either dexamethasone in one of four dosages: 50 microg/kg (Group 1), 100 microg/kg (Group 2), 200 microg/kg (Group 3) and 250 microg/kg (Group 4) or normal saline (Group 5) prior to corrective surgery for strabismus. Anaesthesia was standardized and included nitrous oxide, pethidine, intubation and the use of muscle relaxant and reversal with neostigmine. Postoperative nausea and vomiting were evaluated in epochs of 0-2 hours, 2-6 hours and 6-24 hours after surgery. Parent satisfaction was assessed 24 hours after surgery and the operated eye was examined for wound infection and delayed healing one week later Dexamethasone was effective in preventing nausea and vomiting after strabismus repair: 57.1% children in Group 1, 42.9% in Group 2, 52.4% in Group 3, and 59.5% in Group 4 were free from postoperative nausea and vomiting compared with 7.1% in placebo group. The lowest dose of 50 microg/kg was as efficacious as the higher dosages of dexamethasone during the 24 hours studied. Of the children who developed postoperative nausea and vomiting those who received dexamethasone had significantly fewer episodes than those in the placebo group. We conclude that dexamethasone 50 microg/kg is effective for the prevention of postoperative nausea and vomiting following strabismus repair in children.

Effect of epidural morphine on minimum alveolar concentration of isoflurane in humans.

BACKGROUND AND AIMS: The anaesthetic potency of volatile anaesthetic agents is measured by the minimum alveolar concentration (MAC) required to suppress response in 50% of subjects. We studied the effect of epidural morphine on MAC of isoflurane in humans. SETTINGS AND DESIGN: A prospective single-blind study designed to study the effect of epidural morphine on MAC of isoflurane. SUBJECTS AND METHODS: Forty-eight patients were randomly divided into two groups - Group I patients received 3 mg morphine in 10 ml saline, and Group II patients received 10 ml saline epidurally. Anaesthesia was induced with isoflurane in oxygen and nitrous oxide. Later nitrous oxide was discontinued and MAC of isoflurane determined using modified Dixon's method of sequential sampling. RESULTS: Epidural morphine resulted in a significant reduction in MAC of isoflurane, 0.98 vs. 1.14 in control group (p<0.05). CONCLUSIONS: Epidural administration of 3 mg morphine in 10 ml saline decreased the MAC of isoflurane.

Intrathecal midazolam added to bupivacaine improves the duration and quality of spinal anaesthesia.

BACKGROUND: The antinociceptive action of intrathecal midazolam is well documented. In this prospective study, we investigated the addition of midazolam to intrathecal bupivacaine on the duration and quality of spinal blockade. METHODS: Forty ASA I or II adult patients undergoing lower abdominal surgery were selected for the study. The patients were randomly allocated to receive 3 ml of 0.5% hyperbaric bupivacaine intrathecally either alone or with 1 mg of midazolam using a combined spinal epidural technique. The duration and quality of sensory and motor block, perioperative analgesia, haemodynamic changes, and sedation levels were assessed. RESULTS: The duration of sensory block (i.e. time to regression to the S2 segment) was significantly longer in the midazolam group than the control group (218 min vs. 165 min; P < 0.001). The duration of motor block was also prolonged in the midazolam group as compared with the control group (P < 0.01). In 90% of the patients in the midazolam group, the quality of block was adequate during the intra-operative period as compared with only 65% of the patients in the control group (P < 0.05). The duration of effective analgesia was longer in the midazolam group than in the control group (199 vs. 103 min; P < 0.001). Blood pressure, heart rate, oxygen saturation and sedation scores were comparable in both groups. No neurological deficit or other significant adverse effects were recorded. CONCLUSION: The addition of intrathecal midazolam to bupivacaine significantly improves the duration and quality of spinal anaesthesia and provides prolonged perioperative analgesia without significant side-effects.

Stress ulcer prophylaxis in patients on ventilator.

The objective of the study was to assess the efficacy of the H2-receptor antagonists and sucralfate for the prophylaxis of stress ulcer in patients on a ventilator in an intensive care unit in the general intensive care unit of our institute. A randomized, clinical controlled trial was conducted. Fifty-two critically ill patients, who required mechanical ventilation for more than 24 hours, were randomly divided into 3 groups. Group I received ranitidine 50 mg (intravenous) 8 hourly, group II received tablet sucralfate 1 g 8 hourly through a Ryle's tube, whereas group III was not given any drug. The incidence of upper gastrointestinal bleed, change in gastric pH and growth of gram-negative organisms in the gastric juice and bronchoalveolar lavage (BAL) culture were noted and analysed. The treatment groups were similar with respect to the baseline characteristics. The incidence of upper gastrointestinal bleeding was similar in the ranitidine (12.5%) and sucralfate groups (14.35%) but was high in the control group (57.14%). The mean gastric pH was significantly low in the control group (mean pH 2.07) compared to the ranitidine (mean pH 5.25) and sucralfate groups(mean pH 3.54)(p < 0.05). The incidence of positive culture for gram-negative organisms was significantly high in the ranitidine group (75%) in comparison with the sucralfate group (33.33%) (p < 0.002). However, the incidence of positive growth in the BAL culture was similar in all three groups. We conclude that both ranitidine and sucralfate are equally effective in decreasing the incidence of upper gastrointestinal haemorrhage and other stress- related lesions. Though ranitidine was more effective in increasing the gastric pH, the incidence of gastric colonization was higher in the ranitidine group compared to the sucralfate group.

Remifentanil and propofol sedation for retrobulbar nerve block.

We studied remifentanil and propofol for analgesia and sedation during the placement of an ophthalmic block. Eighty ASA I or II patients undergoing elective cataract surgery under a retrobulbar block in a rural camp setting were included in the study. Patients were randomly divided into four groups and received different drug combinations as follows: Group I--remifentanil 1 microg/kg, Group II--remifentanil 0.5 microg/kg and propofol 0.5 mg/kg, Group III--remifentanil 1 microg/kg with propofol 0.5 mg/kg and Group IV--saline 0.1 ml/kg. Patients were observed for degree of movement, sedation, pain, recall and respiratory depression. No patient in the study groups reported pain or displayed movement whereas most of the patients in the control group had significant pain during the placement of the block. Also, seven (35%) patients in the control group showed significant movement which may have led to failure of block in two patients and retrobulbar haemorrhage in one patient. Incidence of significant respiratory depression was maximum in Group III patients (60%), followed by Group I (20%) and least in Group II (5%). All patients in the study groups remained cooperative and obeyed commands except four patients in group III (OAA/S-4). Postoperatively, other than the control group, recall was maximum in Group I (55%) and least in Group II (5%). Hence, a combination of remifentanil 0.5 microg/kg with propofol 0.5 mg/kg as a bolus was considered to provide excellent relief of pain and anxiety with least adverse effects for the placement of ophthalmic blocks.

Effect of addition of clonidine to local anaesthetic mixture for peribulbar block.

Clonidine added to local anaesthetics prolongs the duration of anaesthesia and analgesia of peripheral, neuraxial and retrobulbar blocks. The present randomized blinded controlled study was conducted to evaluate the effect of the addition of clonidine to local anaesthetic mixture on the quality, onset time, duration of peribulbar block, perioperative analgesia and patients' comfort. The study comprised two groups of 12 patients each. Group A (control) patients received 7 ml of a mixture of 2% lignocaine and hyaluronidase with 1 ml normal saline, while group B (clonidine group) patients had clonidine 1 microg/kg added to the above mixture. Onset and duration of lid akinesia, globe anaesthesia and akinesia, time to first analgesic medication and total analgesic requirement were assessed. Patients were monitored for heart rate, blood pressure, sedation and respiratory depression. Addition of clonidine to local anaesthetic mixture resulted in a significant increase in duration of lid akinesia (85.4+/-25.6 vs 173.3+/-35.3 min, P<0.001), globe anaesthesia (63.2+/-6.9 vs 78.8+/-17.5 min, P=0.012) and globe akinesia (161.3+/-24.3 vs 201.2+/-45.7 min, P=0.016). The onset time and quality of block were similar in both the groups. No significant haemodynamic, respiratory or sedative effects were recorded. The perioperative pain scores and the analgesic requirements were significantly (P<0.01) lower in group B patients. We found that addition of clonidine 1 microg/kg to local anaesthetic mixture significantly increases the duration of anaesthesia and analgesia after peribulbar block.

A dose response study of clonidine with local anesthetic mixture for peribulbar block: a comparison of three doses.

UNLABELLED: Clonidine prolongs anesthesia and analgesia of local anesthetics in various neural blocks as well as the duration of retrobulbar block. We assessed the dose-response relationship of clonidine added to lidocaine in peribulbar block. Sixty patients undergoing cataract surgery were given peribulbar block with 7 mL of 2% lidocaine and hyaluronidase with either saline (Control) or clonidine in 0.5-microg/kg (0.5 Clon), 1.0-microg/kg (1.0 Clon), or 1.5-microg/kg (1.5 Clon) doses. The onset and duration of lid and globe akinesia, globe anesthesia and analgesia, postoperative analgesic requirement, and adverse effects (hypotension, bradycardia, hypoxia, sedation, and dizziness) were recorded. The success rate and onset of block were comparable in all groups. The duration of lid and globe akinesia, globe anesthesia and analgesia was significantly (P < 0.01) prolonged in patients receiving 1.0 and 1.5 microg/kg clonidine as compared with the Control group. Perioperative pain scores and analgesic requirement were significantly less in these groups. 0.5 microg/kg clonidine did not increase the duration of anesthesia and analgesia significantly. Hypotension and dizziness were observed more in patients receiving 1.5 microg/kg clonidine as compared with other groups. We conclude that 1.0 microg/kg clonidine with a mixture of lidocaine (2%) significantly prolonged the duration of anesthesia and analgesia after peribulbar block with limited side effects. IMPLICATIONS: We studied the effect of the addition of 0.5, 1.0 and 1.5 microg/kg clonidine to a lidocaine-hyaluronidase mixture on the onset and duration of peribulbar block and perioperative analgesia. A dose of 1.0 microg/kg produced a significant increase in duration of anesthesia and analgesia with minimal side effects.

Propofol as a sole agent for paediatric day care diagnostic ophthalmic procedures: comparison with halothane anaesthesia.

BACKGROUND: Our aim was to study the feasibility of total intravenous anaesthesia with propofol in spontaneously breathing children undergoing ophthalmic procedures. METHODS: Fifty-five children (aged 6 months to 5 years) were randomly allocated to receive either propofol bolus (until loss of eyelash reflex) followed by infusion [group P (n=29)] or halothane 3-4% for induction, followed by 1-2% in 70% nitrous oxide and oxygen via face mask [group H (n=28)]. Dose for induction and maintenance, intraoperative adverse events, time to recovery (on an Observer's Assessment of Alertness/Sedation Scale, 5 at each level) and duration of procedure were recorded. All children in both groups, were anaesthetized successfully. RESULTS: 4.0 +/- 0.7 mg x kg(-1) and 5.1 +/- 1.0 mg x kg(-1) of propofol were required for loss of eyelash reflex and tolerance of the ophthalmic speculum, respectively. An infusion rate of 8.3 +/- 1.7 mg x kg(-1) x h(-1) was needed for maintenance of anaesthesia; 3.4 +/- 0.5%, 3.6 +/- 0.4% and 1.4 +/- 0.4% halothane was needed for induction, tolerance of the eye speculum and maintenance of anaesthesia, respectively. Induction and recovery were significantly faster with halothane compared with propofol [induction - 38.3 +/- 6.6 s (group H)/60.9 +/- 15.2 s (group P) (P < 0.001); recovery 12.8 +/- 4.6 min (group H)/27.0 +/- 23.3 min (group P) (P < 0.001)]. Apnoea, coughing and breath-holding were seen only in group H. Group P had significantly higher incidence of involuntary movements (minor degree) (n=6) (P < 0.01). CONCLUSIONS: Propofol is a feasible option for paediatric diagnostic ophthalmic procedures with the advantage over halothane of providing complete access to the eye.

Postpartum acquired haemophilia: clinical recognition and management.

Postpartum acquired haemophilia is a rare but serious complication of an otherwise normal pregnancy. Patients usually present with postpartum haemorrhage (PPH) or uncontrolled bleeding following surgical interventions, which fail to respond to conservative treatment. A high index of clinical suspicion along with early laboratory diagnosis and prompt institution of appropriate therapy is essential for the management of acute bleeding episodes. Our patient, a 32-year-old female, presented with severe PPH and shock. She had undergone dilation and curettage three times, with subsequent total abdominal hysterectomy and internal iliac artery ligation, before she was diagnosed with acquired haemophilia (factor VIII autoantibodies) and an inhibitor level of 8 Bethesda units (BU). The patient underwent an abdominal laparotomy for removal of the abdominal packing used in the previous operation, and blood and blood clots, and was given FEIBA(R) therapy. The patient responded to these measure and the factor VIII inhibitor level decreased to 2 BU at the time of discharge 10 weeks later.

Intra-ocular pressure and haemodynamic changes after tracheal intubation and extubation: a comparative study in glaucomatous and nonglaucomatous children.

This prospective, controlled study was conducted to compare the effects of tracheal intubation and extubation on intra-ocular pressure changes and haemodynamic parameters in paediatric patients with and without glaucoma. The children were scheduled for intra-ocular surgery. Twenty children with normal intra-ocular pressure and 15 with glaucoma were studied. A standardised general anaesthetic was administered to both groups. After 5 min of anaesthesia, intra-ocular pressure, heart rate and noninvasive blood pressure were measured. These measurements were repeated 30 s and 2 min after tracheal intubation. Further measurements were taken before, and 30 s and 2 min after extubation. The increase in intra-ocular pressure after intubation was greater in the glaucomatous group than in the normal group. The increase in intra-ocular pressure was greater after extubation than intubation in both groups, but was similar in the two groups. However, because of the already increased intra-ocular pressure in glaucomatous children, they may be at an increased risk of visual damage after intubation and extubation.

Retroperitoneoscopic excision of phaeochromocytoma--haemodynamic events, complications and outcome.

Over a period of 15 months, 11 patients with phaeochromocytoma underwent retroperitoneoscopic excision of their tumours. Five patients had bilateral tumours. All patients underwent thorough preoperative evaluation and preparation with alpha- and beta-blockade. In the majority of the patients a hypertensive response was seen during generation of pneumoretroperitoneum. However, the period of tumour dissection and excision was devoid of large haemodynamic fluctuations. The average time taken was 3.5 to 4 hours per gland. Blood loss in successful laparoscopic excision averaged 240 ml (range 120 to 700 ml). In these patients satisfactory postoperative analgesia could be provided with intramuscular pethidine or intramuscular diclofenac sodium. In three patients the procedure had to be converted to open laparotomy due to haemorrhage. All three patients had preoperative radiological evidence of inferior vena cava and aortic involvement. Patient selection plays an important role in a successful outcome.

Over-the-needle versus microcatheter-through-needle technique for continuous spinal anesthesia: a preliminary study.

BACKGROUND AND OBJECTIVES: A new catheter-over-needle design (Spinocath, B. Braun) has been developed to minimize problems and complications of continuous spinal anesthesia with microcatheters, which include difficult catheter insertion, failure of insertion, breakage, inadequate anesthesia, postdural puncture headache, and, rarely, development of cauda equina syndrome. METHODS: A comparative evaluation of this new catheter (22-gauge Spinocath) to the microcatheter (28-gauge Portex) was performed to study the problems of insertion, complications, quality of anesthesia, and postoperative analgesia in a prospective, randomized manner. Patients were allocated to two groups of 10 each: catheter-over-the-needle group (group I) and microcatheter-through-the needle (group II). Postoperative protocol consisted of an infusion of 0.125% isobaric bupivacaine delivered with a syringe infusion pump for 24 hours. RESULTS: The two groups were comparable in relation to age, sex, type of surgery, median height of the block, and the time taken for catheter insertion and surgery. Spontaneous backflow of cerebrospinal fluid (CSF) through the catheter with the needle in position was possible only in the spinocath group (8/10 cases). Initial introduction of the catheter into the subarachnoid space (8 vs 3: chi-square = 5.05; P = .03) and threading of the catheter were easier (8 vs 3 cases: chi-square = 5.05; P = .03) in group I. Aspiration of CSF was easy in group I in all ( 10 vs 2: chi-square = 13.33; P = .004). Complications such as resistance to drug injection, kinking (P < .05), inadequate anesthesia, and supplementation with general anesthesia were seen only in group II. Postoperative pain relief was comparable in both groups (P > .05). Both groups were comparable hemodynamically in the intra- and postoperative periods. CONCLUSIONS: Insertion, maintenance, and clinical effects were better achieved with the catheter-over-the needle design compared to the microcatheter. These preliminary findings need to be confirmed by a larger study.

Biochemical hemodynamic and hematological changes during transcervical resection of the endometrium using 1.5% glycine as the irrigating solution.

OBJECTIVE: To study fluid absorption during transcervical resection of the endometrium (TCRE) and its effect on the biochemical, hemodynamic and hematological alterations so that life threatening complications of fluid overload may be prevented. METHOD: Intraoperative fluid (1.5% glycine) absorption in 46 women undergoing TCRE was studied and correlated using biochemical parameters (serum sodium, potassium, total proteins, creatinine and blood urea), hemodynamic parameters (pulse rate, blood pressure, oxygen saturation and end tidal CO2) and hematological parameters. Twenty five of these patients had received danazol (800 mg/day) for six weeks prior to TCRE. RESULT: The mean glycine deficit during TCRE was found to be 474.45 ml, with a mean total inflow of 3802.17 ml. Amongst all of the parameters, only serum sodium levels were found to be significantly inversely correlated with the glycine deficit. No case of hyponatremia occurred below a deficit of 1000 ml. Severe hyponatremia was reported in three cases (6.4%) and all three had a glycine deficit of more than 1000 ml. No case of pulmonary edema was noted. The mean glycine deficit was significantly lower (P=0.007) and the duration of procedure significantly shorter (P=0.0009) in the patients who had received danazol. None of the patients in the danazol group had fluid absorption of more than 1000 ml. CONCLUSION: Close monitoring of fluid inflow and outflow should be done during TCRE. Above a deficit of 1000 ml, serum sodium should be measured to detect significant hyponatremia. The use of danazol for endometrial preparation also reduces the mean amount of fluid absorbed.

Laryngeal changes following long-term stenting with polyvinyl chloride tubes.

BACKGROUND: To treat tracheal stenosis and permit wound healing to occur an inert stent is required which resists the contraction process and prevents re-stenosis. The newer stents of polyvinyl chloride are not readily available in India and endotracheal tubes are used in many centres. In our centre polyvinyl chloride tubes are used nasotracheally for prolonged periods. We prospectively studied the pattern of laryngeal changes that occur because of prolonged nasotracheal stenting with polyvinyl chloride tubes. METHODS: The incidence and pattern of laryngeal changes due to stents was prospectively studied at the time of removal of stents, using an operating microscope. Twenty-nine patients underwent tracheal reconstructive surgery for tracheal stenosis (post-intubation or post-tracheostomy) and tracheal injuries. RESULTS: Twelve different lesions were noted and their pattern was related to the period of stenting. Fibrosis, fibrous band formation and webs were noted after four weeks. A high incidence of laryngeal changes was seen in all age groups with an overall incidence of 79% (males 79%; females 88%; adults 82%, children 75%). The mean (SD) duration of stenting was 50 (33) days. Patients with laryngeal changes had a significantly (p < 0.05) longer duration of stenting [56 (34) days] compared to those without any lesion [29 (15) days]. CONCLUSIONS: After four weeks of stenting the severity and incidence of laryngeal changes increase. We recommend restriction of the use of polyvinyl chloride stents to less than four weeks to prevent permanent laryngeal damage.

A profile of nutritional practices and its cost in an intensive care in India.

In a retrospective study fifty patients admitted to a combined medical and surgical intensive care unit were surveyed to see the pattern of nutritional support. The routine practices of initial assessment and monitoring of the nutritional state, ordering and technique of feeding, routes of administration and complications were noted over a 3 week period. This gives an idea of the pattern of care and problems associated with nutritional support of the critically ill in this part of the world. The average cost of parenteral nutrition for three weeks was approximately Rs. 25,960 ($865 approx.) per patient.

Postoperative pulmonary complications in patients with preoperative lung disease.

A prospective study was carried out on the incidence of pulmonary complications in 728 patients who underwent major surgical procedures at a reputed hospital in New Delhi. These patients were preoperatively assessed on the basis of history, clinical examination and bedside pulmonary function tests including PEFR, VC, FVC and FEV1. On the basis of these criteria, 212 patients had significant preoperative pulmonary disease, while 516 had normal lung functions. Postoperative pulmonary complications developed in 7.69 per cent of the patients. They were more frequent in smokers (P < 0.001) and in those with preoperative pulmonary dysfunction (P < 0.001). Their incidence was greater following thoraco-abdominal and musculoskeletal and miscellaneous operations compared to lower abdominal surgery (P < 0.001). The incidence was also higher following exposure to general anaesthesia compared to regional anaesthesia (P < 0.05). Pneumonia and atelectasis were the most common postoperative pulmonary complications. It was observed that the recovery of pulmonary functions was delayed in patients who developed postoperative pulmonary complications.

Phenytoin reduces suxamethonium-induced myalgia.

A prospective, randomised trial was undertaken in 60 healthy adults to determine the efficacy of intravenously administered phenytoin in doses of 5 mg.kg-1 for the prevention of suxamethonium-induced fasciculations, a rise in serum K+ and myalgia. This was compared with tubocurarine pretreatment and no pretreatment (control group). Phenytoin pretreatment significantly reduced myalgia from 45% (nine patients) in the control group to 10% (two patients) (p less than 0.05). It also decreased the duration and mean intensity of fasciculations. Incidentally, phenytoin was also found to decrease significantly mean serum Na+ levels (p less than 0.001) both at 5 and 20 min after administration. Tubocurarine pretreatment (3 mg) resulted in a significant decrease in fasciculations, but myalgia, which occurred in five patients, remained the same. No significant correlation was found between muscle fasciculations, postoperative myalgia and K+ changes, but patients with myalgia had a significant decrease in mean serum Na+ levels at 5 and 20 min after suxamethonium (p less than 0.01).