A comparison of midazolam co-induction with propofol priming in propofol induced anesthesia.

BACKGROUND: Combination therapy with two or more different drugs, with the intension of reaching the same therapeutic goal, was heavily criticized for a long time. However, it is accepted today, especially when advantage over monotherapy can be proved. Our study was undertaken to compare whether propofol priming and midazolam predosing would affect total induction dose requirement of Propofol. METHODS: A prospective randomized, double blind control study was conducted where 120 patients (16-65 years) were divided into 3 groups. Group P received 0.4 mg/kg of Propofol, Group M received 0.05 mg/kg of Midazolam and Group N received 3 ml of Normal Saline 5 minutes after intravenous pethidine 0.75 mg / kg given for analgesia. We compared the total dose of propofol requirement for induction of anaesthesia in all the 3 groups, taking loss of verbal contact as the end point. Additionally, changes in haemodynamic status like blood pressure and heart rate at various intervals were studied and compared among the groups. RESULTS: The groups were similar in terms of age, sex, weight and American Society of Anesesthesiologists Physical Status.The dose of Propofol required to induce anesthesia in Midazolam group was 1.58 mg/kg,1.86 mg/kg in Propofol group and 1.96 mg/kg in the control group. There were less hemodynamic changes in Midazolam group compared to the other two. CONCLUSIONS: Pre-dosing with Midazolam is more effective than Propofol priming in reducing the dose of Propofol induced anaesthesia associated with minimum hemodynamic alterations.

Use of gabapentin, esmolol or their combination to attenuate haemodynamic response to laryngoscopy and intubation.

BACKGROUND: Laryngoscopy and intubation increases blood pressure and heart rate. OBJECTIVE: The study aims to investigate the effect and safety of gabapentin, esmolol or their combination on the haemodynamic response to laryngoscopy and intubation. METHODS: A total of 72 patients undergoing elective surgery were randomly allocated to one of the four groups. First study drug was administered orally as gabapentin 1200mg or placebo. Second study drug was administered intravenously as esmolol 1.5mg/ kg or normal saline. Heart rate, rate pressure product, systolic blood pressure and mean arterial pressure were recorded at baseline and at zero, one, three and five minutes after tracheal intubation. RESULTS: Baseline values were compared with the values at various time intervals within the same group. In group PE (placebo, esmolol), there was significant decrease in heart rate and rate pressure product at five minutes. In group GN (gabapentin, normal saline), there was significant decrease in systolic blood pressure and mean arterial pressure at five minutes. In group GE (gabapentin, esmolol), there was significant decrease in heart rate at zero, three and five minutes. Systolic blood pressure, mean arterial pressure and rate pressure product was significantly lower at three and five minutes. In group PN (placebo, normal saline), there was significant increase in heart rate at zero, one, three and five minutes; systolic blood pressure at zero and one minutes; mean arterial pressure at zero and one minutes and rate pressure product at zero, one and three minutes. In group GN (gabapentin, normal saline), there was significant increase in heart rate at zero, one and three minutes and rate pressure product at zero, one and three minutes. In group PE (placebo, esmolol), there was significant increase in systolic blood pressure at zero and one minutes and mean arterial pressure at zero and one minutes. However, in group GE (gabapentin, esmolol) none of the variables showed statistically significant increase at any time. Inter-group comparison was made for each time point. At zero minute, there was significant difference in heart rate between groups PN and GE, GN and PE and GN and GE Significant difference was also noted in rate pressure product between PN and GE at zero minute. At one minute there was difference in heart rate between PN and PE, PN and GE, GN and PE and between GN and GE. Significant difference was observed in rate pressure product between PN and PE amd between PN and GE at one minute. No significant side effects of the study drugs were observed. CONCLUSIONS: Combination of gabapentin and esmolol in this study design is safe and better attenuates both the pressor and tachycardic response to laryngoscopy and intubation, than either agent alone.

Unexplained apnoea and loss of consciousness during sub arachnoid block for caesarean section.

Sub arachnoid block (SAB) is often perceived safe by many anesthesiologists and other faculties but is also not completely safe choice especially in pregnant females, as the incidence of complications and local anaesthetic agent toxicity is high in these groups of patients. Here we present four such cases out of the seventeen patients over a period of six months, who developed apnea and transient loss of consciousness after spinal anesthesia for lower segment caesarean section. Typically all these patients after spinal anesthesia developed difficulty in breathing, became apnoea and had loss of consciousness for about a minute or two. The apnea was relieved with bag and mask ventilation following which the patient regained consciousness and start breathing normally. The rest of the procedure was uneventful. We presented these cases with aim of sharing similar experiences, and to aware about the possibility of such events as these events do occur frequently but case reports and literatures are unavailable.

Blind nasal intubation in a child with ankylosis of temporomandibular joint.

Blind nasal intubation has been one of the favoured methods of intubating the trachea in patients with restricted mouth opening and thus a difficult laryngoscopy and oro-tracheal intubation. Here, we describe airway management of patient who presented with traumatic ankylosis of the right temporomandibular joint and reduced mouth opening that was planned for elective release of the ankylosis and temporalis fascia flap. Successful blind nasotracheal intubation was done and after the surgery was completed, awake extubation was done and mouth opening was significantly increased. The recovery and the post-operative periods were uneventful.

Application of "the Sequential Organ Failure Assessment (SOFA) score" in predicting outcome in ICU patients with SIRS.

BACKGROUND: Various scoring systems have been developed to prioritize patient admission and management in ICU. The objective of this prospective, observational cohort study was to evaluate application of one such system, the Sequential Organ Failure Assessment (SOFA) Score in predicting outcome in ICU patients with SIRS. PATIENTS AND METHODS: Fifty patients admitted to a six bed multidisciplinary ICU with SIRS were consecutively enrolled in the study and SOFA scores were calculated at zero hour, after 48 hrs, and after 96 hrs and patients followed till discharge from hospital. RESULTS: When compared to outcome, the non survivors had high initial, mean and highest SOFA scores as compared to survivors. (p value = 0.002, <0.001, <0.001 respectively). Delta SOFA was not significantly associated with outcome. (p value= 0.117). The initial SOFA score > 11 predicted a mortality of 90%. (OR 23.72, 95%CI2.68-209.78, p=0.004). Similarly, mean SOFA score of > 7 predicted a mortality of 73.9% (OR 22.7, 95%CI 5.0 - 103.5, p<0.001) and high SOFA score > 11 predicted a mortality of 87.5% (OR 32.66, 95%CI 5.82-183.179, p< 0.001). Area under receiver operating characteristic (ROC) curve for mean SOFA was 0.825, for high SOFA was 0.817 and for initial SOFA was 0.708. Thus mean, high and initial SOFA scores were helpful in predicting between the survivors and the non survivors. CONCLUSION: The SOFA scoring system is useful in predicting outcomes in ICU and thus help in proper utilization of ICU resources.