The requirement of propofol for induction of anesthesia in patients with traumatic brain injury determined using bilateral bispectral index and target controlled infusion - An observational cohort study.

Background and Aims: Patients with traumatic brain injury (TBI) frequently require emergency surgery. There is a paucity of literature with regard to anesthetic requirements in these patients. The aim of the study was to compare the dose of propofol required for induction of anesthesia in patients with different grades of TBI. Material and Methods: This prospective, observational study included patients with mild, moderate, and severe grades of TBI undergoing emergency surgery within 48 h of injury. Bispectral Index (BIS) values were recorded using a bilateral BIS sensor. Anesthesia was induced with a target controlled infusion (TCI) pump. Once BIS reached 40, plasma (Cp) and effect-site (Ce) concentration and total dose of propofol required were noted from the TCI pump. Results: Of the 96 patients recruited, 27, 36, and 33 patients belonged to mild, moderate, and severe TBI (sTBI) groups, respectively. The Ce of propofol in mild, moderate, and sTBI groups was 6 ± 0.9, 5.82 ± 0.98, and 4.48 ± 1.5 µg/mL (P < 0.001), and the dose of propofol required was 1.9 ± 0.2, 1.8 ± 0.4, 1.41 ± 0.5 mg/kg, respectively (P < 0.001). Baseline BIS on the injured side was 80 ± 7.8, 71 ± 9.4, 55 ± 11.6, and on the uninjured side was 89 ± 5.5, 81 ± 8.4, and 65 ± 12 in mild, moderate, and sTBI groups, respectively. Conclusions: The requirement of propofol was reduced in patients with sTBI. The dose of propofol required for induction of anesthesia as determined using Ce was significantly lower only between sTBI and mild TBI and not between patients with sTBI and moderate TBI or between mild and moderate head injury. BIS values were significantly different between the groups (highest in mild TBI and lowest in sTBI) and between normal and injured sides within each group.

Effect of Opioid Versus Non-Opioid Analgesia on Surgical Pleth Index and Biomarkers of Surgical Stress During Neurosurgery for Brain Tumors: Preliminary Findings.

BACKGROUND: Stress response to surgery is mediated by the sympathetic nervous system and manifests as changes in hemodynamic and neuroendocrine parameters. Recently, the surgical pleth index (SPI) is employed for objective and continuous monitoring of nociceptive response during surgery. Opioids are the mainstay of managing stress response to nociception during the perioperative period. However, due to the well-known adverse effects of opioids, α2 agonists are increasingly used to ablate stress response and reduce opioid usage. OBJECTIVES: This study compared SPI and biomarkers of surgical stress between opioid (fentanyl) and non-opioid (dexmedetomidine) analgesia during craniotomy. METHODS: Patients aged 18 to 60 years undergoing elective craniotomies for brain tumor resection under general anesthesia were randomized to receive fentanyl 1 µg/kg/h or dexmedetomidine 0.5 µ/kg/h infusion as the primary intraoperative analgesic. Our objective was to compare SPI and biomarkers of surgical stress-serum cortisol, blood glucose, arterial pH, and leucocyte count between the two groups. RESULTS: Data of all 24 patients recruited into the study were analyzed. There was no difference in the demographic parameters between the groups. The SPI remained similar with both the drugs over various time points during the study period. There was no difference between the groups in the biomarkers of surgical stress-cortisol, blood glucose, and pH while leucocyte count was higher in the fentanyl group. CONCLUSIONS: The stress response to surgery during craniotomy for brain tumors is similar with opioid (fentanyl) and non-opioid (dexmedetomidine) analgesia as assessed by SPI and blood markers such as cortisol, glucose, and pH.

Comparison of intraoperative fentanyl with dexmedetomidine for perioperative analgesia and opioid consumption during craniotomies: A randomised controlled pilot study with non-inferiority design.

BACKGROUND: Moderate to severe pain is common despite the use of potent opioids during craniotomies. Non-opioid agents such as dexmedetomidine reduce undesirable opioid effects and are successfully used as primary analgesic during bariatric surgeries. This study assessed the feasibility of conducting a large randomised controlled trial comparing fentanyl with dexmedetomidine for perioperative analgesia during craniotomy. METHODS: This was a prospective single-centre randomised controlled feasibility trial. Twenty-four consenting adult patients undergoing supratentorial craniotomy at NIMHANS, Bangalore, India, were recruited after ethical approval in March and April 2018. They received either fentanyl 1 µg kg-1  h-1 (n = 12) or dexmedetomidine 0.5  µg kg-1  h-1 (n = 12) as primary intraoperative analgesic drug. Patient, anaesthesiologist, outcome assessor and data analyst were blinded to the study intervention. Our feasibility outcomes (primary) were recruitment and adherence rates. We also explored the potential efficacy of intervention and adverse events. RESULTS: We recruited 24 out of 30 eligible patients and had 100% protocol adherence, thereby demonstrating the feasibility of a larger randomised controlled trial. All 24 patients completed the study. The demographic and clinical parameters were similar between the groups. Compared between fentanyl and dexmedetomidine, there was no difference in the intraoperative fentanyl (top-up) consumption (µg), expressed as median and interquartile range: 25 (0-50) and 0 (0-50); P = 0.844; and no difference in postoperative pain at 15 and 60 minutes. Adverse events were few and similar with fentanyl and dexmedetomidine. CONCLUSIONS: A large-scale randomised controlled trial of perioperative dexmedetomidine versus fentanyl is feasible. Dexmedetomidine has the potential to be non-inferior to fentanyl for perioperative analgesia during craniotomies.

Anaesthetic management of beta thalassemia major with hypersplenism for splenectomy in pediatric age group: Report of four cases.

Beta thalassemia is the most common cause of hemolytic anemia in India. Hereby we are reporting four cases of beta thalassemia major aged between 5 and 10 years posted for splenectomy over a period of 2 months. These patients were on repeated blood transfusions since the day of diagnosis, and two patients had a history of cardiac failure. In addition to emphasizing the anesthetic challenges, the purpose of reporting such cases is to raise the awareness of the disease and prevention of the same by aggressive screening and prenatal diagnosis.