Effects of bilateral transmucosal sphenopalatine ganglion block on intraoperative anesthetic requirements and recovery profile in children undergoing palatoplasty under general anesthesia.

Background and Aims: Sphenopalatine ganglion block (SPGB) given as injection provides excellent perioperative analgesia during palatoplasty. Our objectives were to assess the effect of transmucosal SPGB on anesthetic requirements, intraoperative hemodynamics, recovery time, and emergence delirium in children undergoing palatoplasty. Material and Methods: This prospective, randomized study was conducted in 30 children with cleft palate undergoing palatoplasty, divided into two equal groups. After induction and intubation, patients in Group B received bilateral SPGB using cotton-tipped applicators soaked in 2% lignocaine, which were passed through both the nares, and the distal tip was positioned just superior to middle turbinate and anterior to pterygopalatine fossa and sphenopalatine ganglion. In Group C, saline-soaked cotton applicators were used. All patients received general anesthesia as per a standardized protocol. Intraoperative heart rate, mean arterial pressure, the requirement of anesthetics, extubation time, and emergence delirium were compared. Results: Compared with Group C, patients in Group B had significantly lower sevoflurane consumption (17.2 ± 2.6 vs. 27.5 ± 5.0mL, P < 0.001) and fentanyl consumption (2.2 ± 0.5 vs. 3.2 ± 0.6 µ/kg, P < 0.001).The extubation time was significantly shorter in Group B (3.9 ± 0.7 vs. 9.5 ± 1.6 minutes, P < 0.001). PAED (Pediatric Anesthesia Emergence Delirium Scale) scores at 5and 10 minutes were significantly higher in Group C (P < 0.001). Intraoperative heart rate was significantly higher in Group C. Group C had significantly higher mean arterial pressure at 15, 60, and 75 minutes. Conclusion: Preoperative, SPGB administered by mucosal application of local anesthetic significantly reduced sevoflurane and fentanyl requirements, with stable hemodynamics, quicker recovery, and less emergence delirium in children undergoing palatoplasty.

Comparison of aerosol box intubation with styletted endotracheal tube and intubation over bougie: A randomized controlled trial.

Background and Aims: Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is an infectious disease. The use of video laryngoscopes is recommended for intubation of patients with COVID-19. But in resource-poor countries, it is rare to have video laryngoscopes available. In this trial, we have compared the ease of oral intubation by direct laryngoscopy with styletted endotracheal tube and intubation over the bougie, with the use of the aerosol box. The secondary objectives were comparison of the incidence of airway loss, attempts taken to intubate, time for intubation and hemodynamic changes. Material and Methods: 80 non-coronavirus infected patients coming for an elective procedure under general anesthesia were recruited in this randomized control trial. Participants were assigned into groups S and B using a computer-generated random sequence of numbers by closed envelope technique. In both groups, aerosol box was used. In Group S, participants were intubated by direct laryngoscopy with a styletted endotracheal tube and in group B, after direct laryngoscopy, the endotracheal tube was railroaded over the bougie. Results: Ease of endotracheal intubation was good (67.5%% vs. 45%), satisfactory (32.5%% vs. 37.5%), and poor (0% vs. 17.5%) in group S and B respectively (P < 0.011). The attempts required for intubation were similar in both groups. The time for intubation was significantly less in group S than B (23 vs. 55 s). Conclusion: The use of a styletted endotracheal tube made intubation easier and faster than tracheal intubation with bougie when the aerosol box was used in patients without known or predicted difficult airway and significant medical comorbidities.

Usefulness of bougie-preloaded proseal laryngeal mask airway versus digital insertion technique in correct placement of the device.

Background and Aims: Digital technique of proseal laryngeal mask airway (PLMA) insertion carries high chance of failed first attempt successful placement. We aimed to compare the number of attempts taken for correct placement of bougie-preloaded PLMA versus traditional digital insertion technique. Ease of insertion, time taken, hemodynamic responses during insertion, and evidence of trauma were also assessed. Material and Methods: This prospective, randomized, open-label study was performed in 60 patients. All patients were administered general anesthesia according to a standardized protocol.After induction of general anesthesia in group P, proseal insertion was performed following the traditional digital technique. In group B, bougie-preloaded PLMA was used. A soft gum elastic bougie was passed through the gastric channel of PLMA, with 15cm protruding distally through the gastric port. Attempts at successful insertion and ease of insertion were noted. Results: Time taken for successful insertion was significantly shorter in group B compared to group P (15.3 ± 4.5 vs. 57 ± 12.02 s, respectively). The first attempt success in group B was 90% versus 60% in group P. The number of moderate to hard insertion was significantly lesser in group B (10 vs. 40, respectively). Blood stain on device was seen in 3.3% in group B compared to 30% in group P. MAP at insertion and at 1, 3, and 5 min was significantly higher in group P. Heart rates were comparable. Conclusion: Bougie-preloaded proseal insertion has significantly higher first attempt insertion success rates and is significantly faster and less traumatic with blunted blood pressure response compared to traditional digital insertion technique.

Effects of oral melatonin premedication on hemodynamic responses to intubation, anesthetic requirements and postoperative sedation: A randomized trial.

Background and Aims: Sedative effects of melatonin may have an additive effect on general anesthesia (GA). We compared hemodynamic response to intubation following oral premedication with melatonin versus placebo. Induction dose of propofol, isoflurane and fentanyl consumption were also compared. Material and Methods: This prospective, double-blinded study was conducted in fifty patients randomized into two equal groups. Group M received oral melatonin 6 mg and group P a placebo two hours before surgery. All patients were induced with intravenous propofol of 1.5-2.5mg/kg till loss of response to verbal commands, three minutes after vecuronium, laryngoscopy was done and trachea was intubated. Heart rate (HR) and mean arterial pressures (MAP) were recorded before premedication, before induction, immediately after induction and then at 1,3,5 and 10 minutes after intubation. Results: Mean HR was comparable in both groups throughout the study period. Group M had significantly lower MAP before induction and immediately after induction (P < 0.05). At all other time points MAP remained comparable in both groups. Mean isoflurane consumption was significantly lower in group M compared to group P (14.8 ± 4.2 vs 19.7 ± 3.2 mL). Propofol requirement for induction was also significantly lower in group M (102.4 ± 19.6 vs 122.4 ± 26.3mg). Intraoperative fentanyl consumption was comparable. Conclusion: Oral premedication with melatonin 6mg administered two hours before surgery significantly reduced MAP before and after induction of GA with a significant reduction in dose of propofol requirement. Titrating induction dose of propofol till loss of response to verbal commands did not effectively attenuate responses to laryngoscopy and intubation following melatonin oral premedication.

Usefulness of ultrasound in confirming the correct placement of Ryle's tube compared to the traditional method of auscultation in normal versus overweight and obese patients.

Background and Aims: Auscultation to verify Ryle's tube position is difficult in obese patients. We compared the usefulness of ultrasonography (USG) versus auscultation in confirming the correct Ryle's tube placement in normal versus overweight or obese patients, time taken for confirmation, and incidence of reinsertion. Material and Methods: A prospective, observational study was carried out on 80 patients. Patients with a body mass index (BMI)>25 kg/m2 formed group O and those with BMI <25 kg/m2 constituted group N. After Ryle's tube insertion correct placement was first confirmed by auscultation. The presence of a gurgling sound over the epigastrium was graded (definite/doubtful/absent). During USG evaluation, if Ryle's tube was not visualized at the subxiphoid region, 20mL of air was injected, looking for dynamic fogging in the stomach. If auscultation yielded doubtful or absent results and USG also failed to confirm, Ryle's tube was repositioned and confirmed. Results: Group O had a significantly higher BMI. Auscultation time and the time taken for USG confirmation were significantly longer in group O. The percentage of patients with definite auscultatory signs was significantly higher in group N. Significantly higher number of patients in group O had doubtful/absent auscultatory signs. Ryle's tube and fogging visualization with USG and the requirement of reinsertion were comparable in both groups. The percentage of patients with definite auscultatory confirmation and definite USG confirmation were comparable in group N. However, in group O, significantly lesser patients had definite auscultatory confirmation compared to definite USG signs. Conclusion: Confirmation of the correct placement of Ryle's tube using ultrasound is easier than auscultation in overweight and obese patients. In normal patients, both techniques are equally useful.

Incidence and Severity of Postoperative Complications in Patients Undergoing Surgery Following COVID-19 Infection at a Tertiary Care Center in South India.

Background: The occurrence of postoperative pulmonary complications (PPCs) and other sequelae of COVID-19 infections like thromboembolic events in patients coming for surgery following COVID-19 infection in the Indian population had not been adequately studied. Aim of the Study: We evaluated the incidence of PPCs, acute kidney injury, and thromboembolic complications such as pulmonary embolism, deep-vein thrombosis, myocardial infarction, stroke, and 30-day mortality rate in post-COVID-19 patients undergoing surgery compared to those without a history of COVID-19 infection. Settings and Design: It was a retrospective, observational, case-control study conducted in a tertiary care center. Materials and Methods: One hundred and sixty-six post-COVID-19 surgical patients were included. A matched control group (n = 166) was formed by choosing patients with no history of COVID-19 who underwent similar surgical procedures under a similar technique of anesthesia. Their medical records were analyzed for the development of postoperative pulmonary and nonpulmonary complications and 30-day mortality. Statistical Analysis Used: Independent samples t-test and Chi-squared test were used for statistical analysis. Results: The mean age of patients in the control group was significantly higher than those in the post-COVID-19 group. The number of patients who received two doses of vaccine was also significantly higher in the control group. Comparison of the distribution of preexisting medical conditions and postoperative complications, duration of hospital stay, and incidence of 30-day mortality did not show any significant difference in both groups. Conclusion: Incidence of postoperative complications, length of hospital stay, and 30-day mortality in post-COVID-19 patients undergoing surgical procedures were comparable with patients with no history of COVID-19 infection.

Comparison of Hemoglobin Values Obtained by Arterial Blood Gas Analysis versus Laboratory Method during Major Head-and-Neck Surgeries.

Background: Accuracy of hemoglobin (Hb) measured by arterial blood gas (ABG) analyzer is considered inferior to laboratory (lab) measurements as it could overestimate Hb levels. Aim of the Study: The study aims to compare Hb measured using ABG versus conventional lab method at the time of major blood loss and in the preoperative and immediate postoperative periods. Settings and Design: It was a prospective, nonrandomized observational study conducted in a tertiary care center. Materials and Methods: The study was conducted in 24 patients undergoing major head-and-neck surgeries. Simultaneous blood samples were sent for Hb measurement by ABG analysis and lab method at induction of anesthesia, when intraoperative blood loss exceeded maximum allowable blood loss, and in the immediate postoperative period. Statistical Analysis Used: Chi-square test, independent sample's t-test, and paired t-test were used for statistical analysis. Results: Mean Hb values obtained by both techniques were significantly different at all time points. Hb obtained by ABG analysis was significantly higher than lab value preoperatively (12.78 ± 2.51 vs. 12.05 ± 2.2, P = 0.038), at maximum blood loss (11.00 ± 2.57 vs. 9.87 ± 2.06, P = 0.006), and in the immediate postoperative period (11.96 ± 2.00 vs. 10.96 ± 2.24 P < 0.001). ABG Hb values were found to be approximately 1 g.dL-1 greater than lab values. Conclusion: Hb measured by ABG analysis was significantly higher than that measured by lab method at the time of major blood loss, preoperatively, and at the immediate postoperative period in patients undergoing major head-and-neck surgeries, with a good correlation of values obtained by both the techniques.

Comparison of arterial to end-tidal carbon dioxide gradient P (a-ET)CO2 in volume versus pressure controlled ventilation in patients undergoing robotic abdominal surgery in the Trendelenburg position. A randomised controlled study.

Background and Aims: Robotic surgery is increasingly prevalent as an advancement in care. Steep head-down positions in pelvic surgery can increase the ventilation-perfusion mismatch and increase ventilatory requirements to offset carbon dioxide (CO2) increases consequent to pneumoperitoneum. The primary objective was to assess the impact of two ventilatory strategies, volume versus pressure-controlled ventilation on the arterial to end-tidal carbon dioxide gradient P (a-ET)CO2 in patients undergoing robotic surgery in the Trendelenburg position. The effects on alveolar to arterial oxygen gradient P (A-a)O2, peak airway pressure (Paw), dynamic compliance (Cdyn) and haemodynamics were also assessed. Methods: Fifty-one patients, 18-75 y, American Society of Anesthesiologists I-III undergoing robotic surgery in Trendelenburg position were randomised to volume-controlled ventilation (Group VCV) or pressure-controlled ventilation (Group PCV). The P (a-ET)CO2 was measured at baseline T0, 10 min after Trendelenburg position T1, 2 h of surgery T2, 4 h T3 and at Te, 10 min after deflation. The P (A-a) O2, Paw, Cdyn, heart rate and blood pressure were also measured at the same time. Results: The P (a-ET)CO2 at T1, T2, T3 and at Te was lower in Group PCV versus Group VCV. The Paw was lower at T1, T2, and T3 and Cdyn higher at T3 and Te in Group PCV at comparable minute ventilation. Haemodynamics and P (A-a)O2 were comparable between the groups. Conclusion: Pressure-controlled ventilation reduces P (a-ET)CO2 gradient, Paw and improves Cdyn but does not affect P (A-a) O2 or haemodynamics in comparison to volume-controlled ventilation in robotic surgeries in the Trendelenburg position.