Diagnostic accuracy of left ventricular outflow tract velocity time integral versus inferior vena cava collapsibility index in predicting post-induction hypotension during general anesthesia: an observational study.

BACKGROUND: Point of care ultrasound (POCUS) is being explored for dynamic measurements like inferior vena cava collapsibility index (IVC-CI) and left ventricular outflow tract velocity time integral (LVOT-VTI) to guide anesthesiologists in predicting fluid responsiveness in the preoperative period and in treating post-induction hypotension (PIH) with varying accuracy. METHODS: In this prospective, observational study on included 100 adult patients undergoing elective surgery under general anesthesia, the LVOT-VTI and IVC-CI measurements were performed in the preoperative room 15 minutes prior to surgery, and PIH was measured for 20 minutes in the post-induction period. RESULTS: The incidence of PIH was 24%. The area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the two techniques at 95% confidence interval was 0.613, 30.4%, 93.3%, 58.3%, 81.4%, 73.6% for IVC-CI and 0.853, 83.3%, 80.3%, 57.1%, 93.8%, 77.4% for LVOT-VTI, respectively. In multivariate analysis, the cutoff value for IVC-CI was >51.5 and for LVOT-VTI it was ≤17.45 for predicting PIH with odd ratio [OR] of 8.491 (P=0.025) for IVCCI and OR of 17.427 (P<0.001) for LVOT. LVOT-VTI assessment was possible in all the patients, while 10% of patients were having poor window for IVC measurements. CONCLUSIONS: We recommend the use of POCUS using LVOT-VTI or IVC-CI to predict PIH, to decrease the morbidity of patients undergoing surgery. Out of these, we recommend LVOT-VTI measurements as it has showed a better diagnostic accuracy (77.4%) with no failure rate.

Etomidate-ketamine versus dexmedetomidine-ketamine for entropy-guided procedural sedation during endoscopic retrograde cholangiopancreatography procedures: A randomized single blind study.

BACKGROUND AND AIMS: The major challenge for the anesthetist in endoscopic retrograde cholangiopancreatography (ERCP) procedures is to provide moderate to deep levels of sedation in prone position with preservation of spontaneous respiratory efforts in shared airway scenario with an endoscopist. These patients have other comorbidities, making them vulnerable to complications during the routinely used sedation with propofol. We compared the entropy-guided efficacy of combination of etomidate-ketamine to dexmedetomidine-ketamine in patients undergoing ERCP. METHODS: This prospective single blind randomized entropy-guided trial was conducted on 60 patients with etomidate-ketamine in group I (n = 30) and dexmedetomidine-ketamine in group II (n = 30). The purpose was to compare etomidate-ketamine versus dexmedetomidine-ketamine for ERCP in terms of intraprocedural hemodynamics with desaturation, onset of sedation, recovery time and endoscopist's satisfaction. RESULTS: Hypotension was observed only in six (20%) patients of group II (p < 0.009). Two patients of group I and three in group II desaturated (Spo2 < 90) briefly during the procedure, but none of the patient required intubation (p > 0.05). The mean time in minutes of onset of sedation was 1.15 in group I and 5.6 in group II (p < 0.001). Endoscopists' satisfaction was better in group I (p ≤ 0.001) and length of recovery room stay was shorter in group I as compared to that in group II (p ≤ 0.007). CONCLUSION: We conclude that entropy-guided intravenous procedural sedation with etomidate-ketamine combination provides faster onset of sedation, stable periprocedural hemodynamics, rapid recovery and fair to excellent endoscopist satisfaction compared to dexmedetomidine-ketamine combination for ERCP.

The diagnostic accuracy of ultrasonography over manual aspiration for gastric reserve volume estimation in critically ill patients.

BACKGROUND: Although gastric reserve volume (GRV) is a surrogate marker of gastrointestinal dysfunction and feeding intolerance, there is ambiguity in its estimation due to problems associated with its measurement. Introduction of point-of-care ultrasound as a tool for anesthetists kindled interest in its use for GRV estimation. METHODS: In this prospective observational study, we recruited 57 critically ill patients and analyzed 586 samples of GRV obtained by both ultrasonography (USG) and manual aspiration. RESULTS: The analysis showed that USG-guided GRV was significantly correlated (r=0.788, P<0.001) and in positive agreement with manual aspiration based on Bland-Altman plot, with a mean difference of 8.50±14.84 (95% confidence interval, 7.389-9.798). The upper and lower limits of agreement were 37.7 and -20.5, respectively, within the ±1.96 standard deviation (P<0.001). The respective sensitivity and positive predictive value, specificity and negative predictive value, and area under the curve of USG for feeding intolerance were 66.67%, 98.15%, and 0.82%, with 96.49% diagnostic accuracy. CONCLUSIONS: Ultrasonographic estimation of GRV was positively, significantly correlated and in agreement with the manual aspiration method and estimated feeding intolerance earlier. Routine use of gastric USG could avoid clinical situations where feeding status is unclear and there is high risk of aspiration and could become a standard practice of critical care.

Comparative Efficacy of Intrathecal Bupivacaine Alone and Combination of Bupivacaine with Clonidine in Spinal Anaesthesia.

INTRODUCTION: Clonidine is an α2 agonist agent that has been used as an adjuvant to local anaesthetics in regional anaesthesia. AIM: This study compared two combinations of bupivacaine and clonidine with bupivacaine alone for surgeries below the level of umbilicus in spinal anaesthesia. MATERIALS AND METHODS: We conducted a randomized double blind study on 90 patients of ASA I and ASA II aged 20-60 years, 30 in each group, undergoing surgery below the level of umbilicus in spinal anaesthesia. For intrathecal block, Group 1 received bupivacaine hydrochloride 12.5mg (2.5ml) in 8% dextrose (0.5% sensorcaine heavy) + 1ml (150µg) of preservative free clonidine. Group 2 received bupivacaine hydrochloride 12.5mg (2.5ml) in dextrose (0.5% sensorcaine heavy) + 0.5ml (75µg) of preservative free clonidine + 0.5ml of normal saline to make the volumes of all the groups same. Group 3 received bupivacaine hydrochloride 2.5ml in 8% dextrose (0.5% sensorcaine heavy) + 1ml of normal saline to make the volumes of all the groups same. Heart rate, NIBP, oxygen saturation and respiratory rate were monitored. The onset and duration of sensory block, the highest dermatomal level of sensory block, motor block, time to complete motor block recovery and duration of spinal anaesthesia were recorded. STATISTICAL ANALYSIS: The data of the study was recorded in the record chart and results were evaluated using statistical tests (ANOVA test, post-hoc turkey hsd test, paired t-test and chi-square test). RESULTS: Demographic data, the incidence and duration of bradycardia were comparable amongst the groups. The duration of sensory and motor block were greatest in group 1, followed by group 2 and group 3 (p <0.01). Decrease in the systolic blood pressure of group 2 and group 3 was noted as compared to group 1. No significant sedation or respiratory depression was observed in any group. CONCLUSION: Addition of clonidine to bupivacaine intrathecally is although a reliable method to prolong spinal anaesthesia but close monitoring for hypotension is desirable.