Effect of Tranexamic Acid on Blood Loss and the Quality of Surgical Field in Transsphenoidal Pituitary Surgeries: Double-Blind Placebo-Controlled Randomized Control Trial.

Background and Aims: Pituitary adenomas are common intracranial neoplasms and several cases require surgery, radiotherapy or radiosurgery. Transsphenoidal access to the pituitary gland is the commonest surgical approach. In microscopic or endoscopic approach to the pituitary, even modest bleeding can significantly worsen the surgical field for the neurosurgeon, lengthen intra-operative time and lead to potentially catastrophic complications. Methods: The investigators hypothesized that administration of tranexamic acid (TXA) would improve the quality of the surgical field and reduce bleeding during transsphenoidal surgery (TSS) of pituitary tumors. Fifty American Society of Anesthesiologists (ASA) physical-status 1 or 2 patients undergoing TSS were randomized into two groups: T and P. Patients in Group T received 25 mg/kg bolus of TXA followed by intraoperative infusion of 1 mg/kg/hour, while those in Group P received a matching saline infusion. The operating neurosurgeon, and the anesthesiologist, who managed the patient and collected data, were blinded to the test drug. Surgical field quality was assessed using the Boezaart scale. A single neurosurgeon performed all the surgeries to ensure consistency in estimating the quality of the surgical field. Results: The median Boezaart score (interquartile range) was 3 (1.0) in Group T and 3.0 (1.5) in Group P (P = 0.03). There was an absolute blood loss reduction of nearly 32% with TXA use. Blood loss in Group T was 334 ± 101 mL, compared to 495 ± 226 mL in Group P (P = 0.002). Conclusion: The administration of TXA significantly improved the quality of surgical field and reduced blood loss in patients undergoing TSS.

Comparison of postoperative cognitive dysfunction with the use of propofol versus desflurane in patients undergoing surgery for clipping of aneurysm after subarachnoid hemorrhage.

BACKGROUND: Cerebral aneurysm rupture is a distinct entity among various causes of cerebrovascular accident. Despite the current concept of early surgical clipping to prevent consequences of ruptured aneurysm in good grade subarachnoid hemorrhage patients, 40-50% have postoperative cognitive dysfunction (POCD) on a long- term basis. Here, we compared the effect of two commonly used anesthetic agents on cognitive function following cerebral aneurysmal surgery, i.e., propofol and desflurane. METHODS: We conducted a prospective double-blind clinical study in 70 patients who were randomized to receive maintenance anesthetic agents either propofol or desflurane. The cognitive functions of patients were studied at the time of the discharge from a hospital or at 2 weeks following surgery whichever was early using the Hindi version of the Montreal Cognitive Assessment scale. The hemodynamic parameters, brain relaxation score at the different time intervals, were also studied. RESULTS: There was no difference between the two anesthetic agents in terms of incidence of POCD (65.4% vs. 82.6%, P > 0.05) at the time of discharge or at 2 weeks following surgery. The mean POCD score in propofol and desflurane group was 22.81 ± 4.45 and 19.09 ± 5.66 which was statistically significant (P-value-0.01). The scores for domains of executive function, attention, and orientation were better with propofol group than desflurane group. Intraoperative hemodynamics and brain relaxation scores were similar in both groups. CONCLUSION: A significant number of patients undergoing aneurysmal neck surgery experienced POCD although incidence remained similar in both groups. However, it appears that mean cognitive score and certain domains of cognitive functions especially the executive function, attention, and orientation were better preserved with the use of propofol when compared to desflurane at the time of discharge or on 2 weeks following surgery whichever was early.

Comparison of bispectral index and end-tidal anaesthetic concentration monitoring on recovery profile of desflurane in patients undergoing lumbar spine surgery.

BACKGROUND AND AIMS: Several techniques have evolved over time to monitor depth of anesthesia and ensure enhanced recovery. This randomized double-blinded trial was designed to compare bispectral index (BIS) or end-tidal anaesthetic concentration (ETAC) monitoring on the recovery characteristics of patients undergoing thoracolumbar spine surgeries. METHODS: Seventy American Society of Anesthesiologist I-II patients of either sex were randomized to Group B - BIS-guided protocol, Group E - ETAC-guided protocol, or Group S - Standard protocol. After intravenous induction, anaesthesia was maintained with desflurane in O2/N2O (50:50) mixture. In BIS, ETAC and Standard groups, inspired end-tidal desflurane concentration was varied to achieve BIS of 45-55, 0.8-1.0 age-corrected minimum alveolar concentration, and haemodynamic parameters within 20% of the baseline, respectively. Time to eye opening (emergence time, the primary outcome), time to extubation, and time to name recall from the discontinuation of the anaesthetic agent were recorded. Incidence of nausea, vomiting, and total analgesic consumption was noted for 24 h. RESULTS: Emergence time (mean ± SD) in ETAC (5.1 ± 1.53 min) and BIS (5.0 ± 2.12 min)-guided groups was significantly lower than Standard group (7.5 ± 2.90 min). Extubation time in ETAC (6.3 ± 2.22 min) and BIS-guided group (6.5 ± 1.78 min) was significantly lower than Standard group (9.0 ± 3.20 min) (P < 0.001). Time to achieve fast track score of more than 12 was significantly less in BIS-guided group (13.12 ± 2.59 min). CONCLUSION: ETAC-guided anaesthesia is comparable to BIS-guided anaesthesia in achieving early recovery.

Comparative evaluation of propofol, sevoflurane and desflurane for neuroanaesthesia: A prospective randomised study in patients undergoing elective supratentorial craniotomy.

BACKGROUND AND AIMS: Both inhalational and intravenous anaesthetic agents are being used for neuroanaesthesia. Clinical trials comparing "propofol and sevoflurane" and "desflurane and sevoflurane" have been published. However, the comparison of all the three anaesthetics in neurosurgical patients has not been done. A randomised clinical study was carried out comparing propofol, sevoflurane and desflurane to find the ideal neuroanaesthetic agent. METHODS: A total of 75 adult patients undergoing elective craniotomy for supratentorial tumours were included in the study. The patients were induced with morphine 0.1 mg/kg and thiopentone 4-6 mg/kg. Neuromuscular blockade was facilitated with vecuronium. The patients were randomised to receive propofol, sevoflurane or desflurane along with nitrous oxide in oxygen for maintenance of anaesthesia. The neuromuscular blockade was reversed following the surgery once the patients opened eyes or responded to verbal commands. The three anaesthetics were compared for their effects on haemodynamics, brain relaxation and emergence characteristics. RESULTS: The mean arterial blood pressure during anaesthesia was comparable among the groups. The patients receiving sevoflurane had faster heart rates intraoperatively when compared to desflurane (P < 0.05). The brain relaxation scores at various intraoperative time frames were comparable among the three groups (P > 0.05). The time to response to verbal commands were significantly prolonged with use of sevoflurane (8.0 ± 2.9 min) when compared to propofol (5.3 ± 2.9 min) and desflurane (5.2 ± 2.6 min) (P = 0.003). However, the time to emergence and the number of patients who had early emergence (<15 min) were comparable among the groups (P > 0.05). The quality of emergence (coughing and emergence agitation), as well as postoperative complications, were also comparable among the three groups. CONCLUSIONS: All the three anaesthetic agents-propofol, sevoflurane and desflurane appear comparable and acceptable with regard to their clinical profile during anaesthesia in patients undergoing elective supratentorial surgeries.

Effect of intramucosal infiltration of different concentrations of adrenaline on hemodynamics during transsphenoidal surgery.

BACKGROUND AND AIMS: Neurosurgeons routinely instill vasopressors, with or without local anesthetics, to prepare nasal passages prior to transsphenoidal surgeries. As there is a paucity of data comparing the effect of intramucosal nasal infiltration of different concentrations of adrenaline that is, 1:200,000 and 1:400,000 in patients undergoing transsphenoidal surgery, we conducted this study to evaluate the effect of these two concentrations of adrenaline with 2% lignocaine on hemodynamics as well as bleeding. MATERIALS AND METHODS: Fifty-two American Society of Anesthesiologists I/II patients, aged 15-70 years, undergoing transsphenoidal surgery for pituitary or sellar masses were enrolled. Prior to surgical incision, nasal septal mucosa was infiltrated with lignocaine-adrenaline solution, after randomly allocating them to one of the two groups, with patients in Group A receiving intramucosal infiltration using 2% lignocaine with 1:200,000 adrenaline and those in Group B receiving 2% lignocaine with 1:400,000 adrenaline. Following infiltration, hemodynamic parameters were recorded every 1 min for 5 min and thereafter at every 5 min interval. RESULTS: Fewer patients (3/24 [12.5%]) in Group B had a rise of >50% in systolic blood pressure, from baseline values, after nasal mucosa infiltration as compared with patients in Group A (9/24 [37.5%]). In addition, mean rise in systolic, diastolic and mean arterial pressure was also significantly lower in Group B as compared with Group A. CONCLUSION: Adrenaline in a concentration of 1:400,000 added to 2% lignocaine for nasal mucosa infiltration produces less hemodynamic response as compared with adrenaline 1:200,000 added to 2% lignocaine while at the same time providing similar operating conditions.

Effect of intranasal dexmedetomidine or oral midazolam premedication on sevoflurane EC50 for successful laryngeal mask airway placement in children: a randomized, double-blind, placebo-controlled trial.

INTRODUCTION: This study was conducted to determine the effect of oral midazolam (OM) or intranasal dexmedetomidine (IND) on the EC50 of sevoflurane for successful laryngeal mask airway placement in children. We hypothesize that premedication with either agent might reduce the sevoflurane EC50 for laryngeal mask airway placement in children to a similar extent. METHODS: Fifty-two American Society of Anesthesiologists (ASA) I children (aged 1-6 years) scheduled for general anesthesia with laryngeal mask airway were randomized to one of the three groups: group M received 0.5 mg · kg(-1) OM with honey and intranasal saline, group D received 2 µg · kg(-1) IND along with oral honey, and group P received oral honey and intranasal saline at least 30 min prior to induction of anesthesia. Anesthesia was induced with incremental sevoflurane up to 8% in 100% O2 . A predetermined target endtidal sevoflurane (ETsevo ) concentration (2% in the first child of all three groups) was sustained for 10 min before the attempt of laryngeal mask airway insertion by adjusting dial concentration. No intravenous anesthetic or neuromuscular blockade was used. ETsevo was increased/decreased (step size 0.2%) using Dixon's and Massey's up and down method in next patient depending upon previous patient's response. Placement of the laryngeal mask airway without movement, coughing, biting, or bucking was considered as successful. EC50 of sevoflurane was calculated as the average of the crossover midpoints in each group, which was further confirmed by probit analysis. RESULTS: The EC50 of sevoflurane for laryngeal mask airway placement after OM (1.66 ± 0.31) and IND (1.57 ± 0.14) premedications was significantly lower than the placebo group (2.00 ± 0.17, P < 0.0001). The EC95 (95% CI) derived from probit regression analysis was 2.34% (2.22-2.51%) with OM, 1.88% (1.77-2.04%) with IND, and 2.39% (2.25-2.35%) with placebo group. CONCLUSIONS: Oral midazolam and IND premedications significantly reduce the sevoflurane EC50 for laryngeal mask airway insertion in children by 17% and 21%, respectively.

[Comparison of the conventional CMAC and the D-blade CMAC with the direct laryngoscopes in simulated cervical spine injury-a manikin study]. / Comparação do C-MAC convencional e C-MAC D-blade com laringoscópios diretos em simulação de lesão da coluna cervical-estudo em modelo.

BACKGROUND: CMAC videolaryngoscope has recently been introduced for videoscope guided intubation. The aim of our study was to compare and evaluate the efficacy of the conventional blade and the angulated D blade of the CMAC videolaryngoscope with the direct laryngoscopes in simulated cervical spine injury patients on the airway manikin. MATERIALS AND METHODS: Following power analysis, 33 resident doctors were enrolled to perform endotracheal intubation using all the 4 different laryngoscopes namely the Macintosh laryngoscope, McCoy laryngoscope, conventional CMAC videolaryngoscope and the D blade of the CMAC videolaryngoscopes on the airway manikin in simulated cervical spine injury. The demographic variables of the resident doctors were recorded. The outcomes measured included vocal cord visualization (Cormack-Lehane grading), time taken to intubate, number of attempts for successful intubation and optimizing maneuvers required. RESULTS: The use of indirect videolaryngoscopes resulted in better glottic visualization in comparison to the direct laryngoscopes (CL-I) in 20/33 (60.6%) in the Macintosh group, 24/33 (72.7%) in McCoy group, 30/33 in (90.9%) in Vlc group and 32/33 (96.9%) in Vld group. The time taken to intubate averaged to 15.54±2.6 in Macintosh group, 18.90±4.47 in McCoy group, 20.21±7.9 in Vlc group and 27.42±9.09 in Vld group. The 1st attempt intubation success rate was 84.8% (Macintosh), 72.7% (McCoy), 90.9% (Vlc) and, 78.7% (Vld). CONCLUSIONS: The overall performance of the conventional CMAC blade proved to be the best when compared with the D-blade CMAC, Macintosh blade and the McCoy blade for intubation in simulated cervical spine patients by anesthesia residents.

Comparison of the conventional CMAC and the D-blade CMAC with the direct laryngoscopes in simulated cervical spine injury--a manikin study.

BACKGROUND: CMAC videolaryngoscope has recently been introduced for videoscope guided intubation. The aim of our study was to compare and evaluate the efficacy of the conventional blade and the angulated D blade of the CMAC videolaryngoscope with the direct laryngoscopes in simulated cervical spine injury patients on the airway manikin. MATERIALS AND METHODS: Following power analysis, 33 resident doctors were enrolled to perform endotracheal intubation using all the 4 different laryngoscopes namely the Macintosh laryngoscope, McCoy laryngoscope, conventional CMAC videolaryngoscope and the D blade of the CMAC videolaryngoscopes on the airway manikin in simulated cervical spine injury. The demographic variables of the resident doctors were recorded. The outcomes measured included vocal cord visualization (Cormack-Lehane grading), time taken to intubate, number of attempts for successful intubation and optimizing maneuvers required. RESULTS: The use of indirect videolaryngoscopes resulted in better glottic visualization in comparison to the direct laryngoscopes (CL-I) in 20/33 (60.6%) in the Macintosh group, 24/33 (72.7%) in McCoy group, 30/33 in (90.9%) in Vlc group and 32/33 (96.9%) in Vld group. The time taken to intubate averaged to 15.54±2.6 in Macintosh group, 18.90±4.47 in McCoy group, 20.21±7.9 in Vlc group and 27.42±9.09 in Vld group. The 1st attempt intubation success rate was 84.8% (Macintosh), 72.7% (McCoy), 90.9% (Vlc) and, 78.7% (Vld). CONCLUSIONS: The overall performance of the conventional CMAC blade proved to be the best when compared with the D-blade CMAC, Macintosh blade and the McCoy blade for intubation in simulated cervical spine patients by anesthesia residents.

Transforaminal versus parasagittal interlaminar epidural steroid injection in low back pain with radicular pain: a randomized, double-blind, active-control trial.

BACKGROUND: Epidural injections are the most common minimally invasive intervention used to manage low back pain with lumbosacral radicular pain. It can be delivered through either transforaminal (TF), interlaminar, or caudal approaches. The TF approach is considered more efficacious than the interlaminar approach probably because of ventral epidural spread. However, catastrophic complications reported with the TF approach have raised concerns regarding its use. These concerns regarding the safety of the TF approach lead to the search for a technically better route with lesser complications with drug delivery into the ventral epidural space. The parasagittal interlaminar (PIL) route is reported to have good ventral epidural spread. However, there is a paucity of literature comparing the effectiveness of PIL with TF. OBJECTIVES: To compare effectiveness of PIL and TF epidural injections for managing low back pain with lumbosacral radicular pain. STUDY DESIGN: Randomized, double-blind, active-control study. SETTING: Interventional pain management clinic in a tertiary care center in India. METHODS: Sixty-two patients were randomized to receive fluoroscopically guided epidural injection of methylprednisolone (80 mg) either through the PIL (n = 32) or TF (n = 30) approach. Patients were evaluated for effective pain relief (≥ 50% from baseline) by 0 - 100 visual analogue scale (VAS) and functional improvement by Modified Oswestry Disability Questionnaire (MODQ) at 2 weeks, 1, 2, 3, 6, 9, and 12 months. Patients who failed to respond to the treatment or when the patient's response deteriorated received additional injection of same injectate, dose, and approach. Only if the pain returns should there be a maximum of 3 injections. Other outcome measures were overall VAS and MODQ, number of injections, and presence of ventral and perineural spread. RESULTS: Effective pain relief (≥ 50% pain relief from baseline on VAS) was observed in 76% (90% CI 60.6 - 88.5%) of patients in the TF group and 78% (90% CI 62.8 - 89.3%) of patients in the PIL (P = 1.00) group at 3 months. The pain relief survival period was comparable in both groups (P = 0.98). Significant reduction in VAS and improvement in MODQ were observed at all time points post-intervention compared to baseline (P < 0.001) in both groups. On average, patients in the PIL group received 1.84 and patients in the TF group received 1.92 procedures annually. The majority received injection at L4-L5 intervertebral level (24 in TF and 23 in PIL). Ventral epidural spread was comparable in both groups (PIL - 91.6% and TF - 89.6%). No major complications were encountered in either group; however, initial intravascular spread of contrast was observed in 3 patients in the TF group. LIMITATIONS: Limitations included lack of documentation of adjuvant analgesic drug therapy and procedures performed by a single experienced interventionalist. CONCLUSIONS: Epidural injection delivered through the PIL approach is equivalent in achieving effective pain relief and functional improvement to the TF approach for the management of low back pain with lumbosacral radicular pain. The PIL approach can be considered a suitable alternative to the TF approach for its equivalent effectiveness, probable better safety profile, and technical ease. TRIAL REGISTRATION: CTRI/2012/08/002938.

Comparison of the conventional CMAC and the D-blade CMAC with the direct laryngoscopes in simulated cervical spine injury-a manikin study / Comparação do C-MAC convencional e C-MAC D-blade com laringoscópios diretos em simulação de lesão da coluna cervical-estudo em modelo / Comparação do C-MAC convencional e C-MAC D-blade com laringoscópios diretos em simulação de lesão da coluna cervical-estudo em modelo / Comparación del C-MAC convencional y C-MAC D-blade con laringoscopios directos en simulación de lesión de la columna cervical (estudio en modelo)

BACKGROUND: CMAC videolaryngoscope has recently been introduced for videoscope guided intubation. The aim of our study was to compare and evaluate the efficacy of the conventional blade and the angulated D blade of the CMAC videolaryngoscope with the direct laryngoscopes in simulated cervical spine injury patients on the airway manikin. MATERIALS AND METHODS: Following power analysis, 33 resident doctors were enrolled to perform endotracheal intubation using all the 4 different laryngoscopes namely the Macintosh laryngoscope, McCoy laryngoscope, conventional CMAC videolaryngoscope and the D blade of the CMAC videolaryngoscopes on the airway manikin in simulated cervical spine injury. The demographic variables of the resident doctors were recorded. The outcomes measured included vocal cord visualization (Cormack-Lehane grading), time taken to intubate, number of attempts for successful intubation and optimizing maneuvers required. RESULTS: The use of indirect videolaryngoscopes resulted in better glottic visualization in comparison to the direct laryngoscopes (CL-I) in 20/33 (60.6%) in the Macintosh group, 24/33 (72.7%) in McCoy group, 30/33 in (90.9%) in Vlc group and 32/33 (96.9%) in Vld group. The time taken to intubate averaged to 15.54 ± 2.6 in Macintosh group, 18.90 ± 4.47 in McCoy group, 20.21 ± 7.9 in Vlc group and 27.42 ± 9.09 in Vld group. The 1st attempt intubation success rate was 84.8% (Macintosh), 72.7% (McCoy), 90.9% (Vlc) and, 78.7% (Vld). CONCLUSIONS: The overall performance of the conventional CMAC blade proved to be the best when compared with the D-blade CMAC, Macintosh blade and the McCoy blade for intubation in simulated cervical spine patients by anesthesia residents. .

JUSTIFICATIVA E OBJETIVO: o videolaringoscópio C-MAC foi recentemente introduzido para orientar a intubação. O objetivo deste estudo foi comparar e avaliar a eficácia do laringoscópio C-MAC de lâmina convencional e C-MAC de lâmina angulada (D-blade) com laringoscópios diretos em simulação de pacientes com lesão de coluna cervical usando modelo de vias aéreas. MATERIAIS E MÉTODOS: após a análise do poder do estudo, 33 médicos residentes foram inscritos para realizar intubações endotraqueais, usando todos os quatro laringoscópios diferentes: laringoscópio Macintosh, laringoscópio McCoy, videolaringoscópios C-MAC convencional e C-MAC D-blade em modelos de vias aéreas com simulação de lesão da coluna cervical. As variáveis demográficas dos médicos residentes foram registradas. Os resultados avaliados incluíram visualização das pregas vocais (classificação de Cormack-Lehane), tempo necessário para intubar, número de tentativas para intubação bem-sucedida e manobras de otimização necessárias. RESULTADOS: o uso de laringoscópios indiretos resultou em melhor visualização da glote em comparação com os laringoscópios diretos (CL-I) em 20/33 (60,6%) no grupo Macintosh, 24/33 (72,7%) no grupo McCoy, 30/33 (90,9%) no grupo Vlc e 32/33 (96,9%) no grupo Vld. A média do tempo necessário para entubar foi de 15,54 ± 2,6 no grupo Macintosh, 18,90 ± 4,47 no grupo McCoy, 20.21 ± 7,9 no grupo Vlc e 27,42 ± 9,09 no grupo Vld. A taxa para a primeira tentativa de intubação bem-sucedida foi de 84,8% (Macintosh), 72,7% (McCoy), 90,9% (Vlc) e 78,7% (Vld). CONCLUSÃO: o desempenho geral da lâmina do C-MAC convencional mostrou ser melhor quando comparado com o das lâminas ...

JUSTIFICACIÓN Y OBJETIVO: el videolaringoscopio C-MAC fue recientemente introducido para orientar la intubación. El objetivo de este estudio fue comparar y evaluar la eficacia del laringoscopio C-MAC de lámina convencional y C-MAC de lámina angulada (D-blade) con laringoscopios directos en una simulación de pacientes con lesión de la columna cervical usando modelo de vías aéreas. MATERIALES Y MÉTODOS: después del análisis del poder del estudio, 33 médicos residentes fueron inscritos para realizar intubaciones endotraqueales, usando 4 laringoscopios diferentes: laringoscopio Macintosh, laringoscopio McCoy, videolaringoscopios C-MAC convencional (Vlc) y C-MAC D-blade (Vld) en modelos de vías aéreas con simulación de lesión de la columna cervical. Las variables demográficas de los médicos residentes fueron registradas. Los resultados evaluados incluyeron la visualización de las cuerdas vocales (clasificación de Cormack-Lehane), tiempo necesario para intubar, número de intentos para intubación exitosa y maniobras de optimización necesarias. RESULTADOS: el uso de laringoscopios indirectos trajo como resultado una mejor visualización de la glotis en comparación con los laringoscopios directos (CL-I) en 20/33 (60,6%) en el grupo Macintosh, 24/33 (72,7%) en el grupo McCoy, 30/33 (90,9%) en el grupo Vlc y 32/33 (96,9%) en el grupo Vld. El tiempo medio necesario para intubar fue de 15,54 ± 2,6 en el grupo Macintosh; 18,90 ± 4,47 en el grupo McCoy; 20,21 ± 7,9 en el grupo Vlc; y 27,42 ± 9,09 en el grupo Vld. La tasa para el primer intento de intubación exitoso fue de un 84,8% (Macintosh), un 72,7% (McCoy), un 90,9% (Vlc) y un 78,7% (Vld). CONCLUSIÓN: el rendimiento global de la lámina del C-MAC convencional mostró ser mejor cuando se le comparó con el de las láminas ...

How safe is the prone position in acute respiratory distress syndrome at late pregnancy?

We encountered a case of severe acute respiratory distress syndrome in late pregnancy due to influenza (H1N1) with refractory hypoxemia to conventional mechanical ventilation. Ventilation in prone position rescued this patient by maintaining oxygenation and sustaining improvement thereafter. Here, we discuss the mechanism of prone ventilation with special references to safety management of acute respiratory distress syndrome in the third trimester of pregnancy. It requires frequent monitoring of possible complications due to prone position and highly dedicated supporting staffs. More data are required on safety of proning in the late pregnancy.

End-tidal concentrations of sevoflurane and desflurane for ProSeal laryngeal mask airway removal in anaesthetised adults: a randomised double-blind study.

BACKGROUND: The optimal end-tidal sevoflurane and desflurane concentration for successful ProSeal laryngeal mask airway (PLMA) removal in unpremedicated anaesthetised adults has not been determined. OBJECTIVES: We determined end-tidal sevoflurane and desflurane concentration in 50% of anaesthetised adults (EC50: concentration at which there is 50% chance of patients showing 'no movement' response) for smooth PLMA removal. DESIGN: Randomised controlled double blind study. SETTING: Operating theatre of a government tertiary care institute. The study period was December 2011 to January 2013. PATIENTS: Thirty nine unpremedicated American Society of Anesthesiologists (ASA) physical status I and II women with cervical carcinoma (aged 30 to 60 years) scheduled for implantation of intracavity caesium under general anaesthesia with PLMA as an airway device were included in the study. INTERVENTIONS: The participants were randomised to one of the two groups receiving either desflurane or sevoflurane for anaesthesia maintenance. Anaesthesia induction was performed with intravenous propofol. Predetermined end-tidal sevoflurane concentration (initiating at 2%) or desflurane (initiating at 4%) was sustained for 10 min before PLMA removal was attempted. End-tidal concentrations were increased/decreased (step-size 0.2% for sevoflurane and 0.5% for desflurane) using Dixon and Massey up and down method in the next patient depending upon previous patient's response. Patient responses to PLMA removal were classified as 'movement' or 'no movement'. MAIN OUTCOME MEASURES: EC50 was calculated as the mean of the crossover pairs' midpoints in each group and further confirmed by probit regression analysis. RESULTS: EC50 (95% confidence interval) of sevoflurane and desflurane for PLMA removal were 1.58% (0.669 to 2.060) and 2.79% (2.733 to 2.841), respectively. CONCLUSION: Predicted EC50 and EC95 of sevoflurane and desflurane for smooth removal for the PLMA were 1.58 (0.669 to 2.060), 2.27 (1.859 to 21.16), 2.79 (2.733.2.841) and 3.27% (3.173 to 3.395), respectively. TRIAL REGISTRATION: Registered with Clinical Trial Registry of India (URL: http://www.ctri.in), Registry ref no: CTRI/2012/12/004285.

Postoperative emergence delirium in pediatric patients undergoing cataract surgery--a comparison of desflurane and sevoflurane.

BACKGROUND: Desflurane and sevoflurane are associated with postoperative emergence delirium (ED) in children. The study aimed to compare the use of desflurane and sevoflurane to determine the postoperative ED in children undergoing cataract surgery using the validated Pediatric Anesthesia Emergence Delirium (PAED) scale. METHODS: In this randomized double-blinded study, 88 children of American Society of Anesthesiologists (ASA) grade I and II aged 2-6 years, anesthesia was maintained with 1-1.2 MAC concentration of desflurane or sevoflurane after induction with sevoflurane. Subtenon block was administered in all children with 0.08-0.10 ml·kg(-1) of 0.5% bupivacaine before surgical incision. Primary outcome measured was PAED scale at different time intervals between the two groups, and secondary outcome measured was preoperative anxiety scores, postoperative pain scores, emergence, incidence of delirium and adverse effects. RESULTS: Pediatric Anesthesia Emergence Delirium (PAED) scale showed no statistical difference between sevoflurane and desflurane at different time intervals. Incidence of ED using the cutoff of >12 in PAED scale was 8 of 44 (18.18%) in sevoflurane group and 9 of 44 (20.45%) in desflurane groups (P = 1.000). Emergence from anesthesia was faster in desflurane group (P = 0.001). Correlation between the m-YPAS anxiety scale and PAED scale in either group did not find any relationship (correlation coefficient = -0.060, P = 0.579). No correlation between the Face, Legs, Activity, Cry and Consolability (FLACC) scale and Pediatric Anesthesia Emergence Delirium (PAED) scale was found in 17 patients who had ED (correlation coefficient = 0.191, P-value = 0.462). Five patients of 17 (i.e., three patients in Group S and two patients in Group D) had PAED >12 but FLACC <4. CONCLUSION: Emergence delirium (ED) after desflurane and sevoflurane anesthesia was comparable using a validated PAED scale in pediatric cataract surgery. There was no correlation between preoperative anxiety and ED in these children; however, children with higher pain scores were more likely to have a higher ED.

Minimum alveolar concentration of desflurane with caudal analgesia for laryngeal mask airway removal in anesthetized children.

BACKGROUND: Regional blocks have been shown to decrease the requirement of anesthetic agents. This study was conducted to determine the optimal endtidal concentrations of desflurane for removal of Laryngeal mask airway in children in presence of caudal block. METHODS: Twenty-two children of ASA status I between the age group of 2-10 year undergoing infraumbilical surgery were enrolled in the study. General anesthesia was induced with sevoflurane and oxygen given via mask and laryngeal mask airway inserted. Caudal injection of bupivacaine 0.25%, 1 ml·kg(-1) was administered according to Armitage regimen. Desflurane was used for maintenance of anesthesia. Predecided endtidal concentration of desflurane was maintained for 10 min at the end of surgery and laryngeal mask airway removed. Target concentration in the next patient was thereafter determined by the Dixon up-down method (with 0.5% as a step size). 5% endtidal concentration was kept as the starting concentration. If removal of laryngeal mask airway was not associated with any coughing, teeth clenching, gross purposeful movement, breath holding or laryngospasm, during or within 1 min after removal, it was considered as successful. RESULTS: In the presence of caudal analgesia, endtidal concentration of desflurane required for successful laryngeal mask airway removal in 50% (ED50) children was 3.39 ± 0.38% by Dixon's method. CONCLUSION: Laryngeal mask airway can be successfully removed in 50% of anesthetized children without coughing, moving, or any other airway complications at an endtidal desflurane concentration of 3.4% in the presence of caudal analgesia.

Efficacy of subtenon block in infants - a comparison with intravenous fentanyl for perioperative analgesia in infantile cataract surgery.

BACKGROUND: General anesthesia with opioids provides good perioperative analgesia in infantile ocular surgeries but is associated with the risk of respiratory depression and postoperative emesis. This study aimed to assess the effectiveness of subtenon block for providing perioperative analgesia in infants undergoing cataract surgeries. METHODS: In this prospective, randomized, controlled, double-blinded trial, 63 infants of ASA grade I and II (1-12 months) were recruited to receive either subtenon block (Group SB) or 1 µg·kg(-1) i.v. fentanyl (Group F) after induction of anesthesia. Primary outcome was the number of infants requiring rescue analgesia during 4-h study period before discharge of the infants. Secondary outcomes assessed were CRIES pain score, incidence of oculocardiac reflex, surgical difficulty, and incidence of postoperative emesis. RESULTS: The number of infants requiring rescue analgesia during 4-h study period was significantly less in Group SB (n = 6/32, 18.8%) compared to Group F (n = 14/31, 45.2%, P = 0.032). CRIES scores were significantly lower at and after 40 min compared to immediate postoperative period in Group F while these were comparable at all time intervals in Group SB. CRIES scores were significantly lower in Group SB compared to Group F at all time intervals except at 1 h. The incidence of oculocardiac reflex and the postoperative emesis were comparable in both the groups. CONCLUSION: Subtenon block is an effective superior technique for postoperative analgesia compared to intravenous fentanyl in infants undergoing cataract surgery.

Lateral parasagittal versus midline interlaminar lumbar epidural steroid injection for management of low back pain with lumbosacral radicular pain: a double-blind, randomized study.

BACKGROUND: Epidural steroid injections are commonly used for management of low back pain with lumbosacral radicular pain and can be administered by either interlaminar or transforaminal routes. The transforaminal route is reported to be more effective than the interlaminar route due to higher delivery of drug at the ventral epidural space. However, the transforaminal route has been associated with serious complications including spinal cord injury and permanent paralysis. Hence, there is a search for a technically better route with fewer complications for drug delivery into the ventral epidural space. Recently, a parasagittal interlaminar (PIL) approach of epidural contrast injection was reported to have 100% ventral epidural spread. However, the therapeutic efficacy of this route has never been investigated. We compared the therapeutic efficacy of the PIL approach and midline interlaminar (MIL) approach. We hypothesized that the PIL approach may produce a better clinical outcome because of better ventral epidural spread of the drug compared with MIL approach. METHODS: Thirty-seven patients were randomized to receive injection of 80 mg methylprednisolone either by the PIL (PIL group, n = 19) or MIL (MIL group, n = 18) approach under fluoroscopic guidance. Patients were evaluated for effective pain relief (≥50% from baseline) by visual analog scale and improvement in disability by the modified Oswestry Disability Questionnaire at intervals of 15 days, 1, 2, 3, and 6 months. Patients having <50% pain relief from baseline received additional epidural injection of the same drug, dosage, and route, a maximum of 3 injections at least 15 days apart. The primary outcome of our study was the incidence of effective pain relief at 6 months. RESULTS: The incidence of patients having effective pain relief was higher with the PIL approach (13/19 [68.4%]) vs MIL (3/18 [16.7%]) at the end of 6 months. A significantly higher relative success of effective pain relief was noted in the PIL group (relative risk, 4.10; 95% confidence interval, 1.40-12.05; P = 0.001) at the end of the 6-month follow up with the requirement of fewer total injections (29 vs 41 in MIL, P = 0.043). Visual analog scale and modified Oswestry Disability Questionnaire scores were significantly lower in the PIL group compared with the MIL group at all time intervals after the procedure. Ventral epidural spread of contrast was significantly higher in the PIL 89.7% vs 31.7% in the MIL group. The administration of epidural steroid injection was without any complications with an exact 95% Clopper-Pearson confidence interval of 0.0% to 17.6% in the PIL group and 0.0% to 18.5% in the MIL group. CONCLUSIONS: Epidural steroid injection administered with the PIL approach was significantly more effective for pain relief and improvement in disability than the MIL approach for 6 months in the management of low back pain with lumbosacral radicular pain.

Cuff filling volumes for pediatric classic laryngeal mask airways: comparison of clinical end points versus adjusted cuff pressure.

BACKGROUND: Clinical end points are often used to guide inflation and adequacy of cuff seal after laryngeal mask airway placement. However, clinical end points for cuff inflation have been shown to have significantly higher intracuff pressure. The adjusted cuff pressure between 55 and 60 cm H(2)O causes significantly better seal of laryngeal mask airway. We prospectively assessed the cuff pressures generated by cuff inflation guided by clinical end points, and the actual volume of air required to achieve cuff pressures between 55 and 60 cm H(2)O for sizes 1-2.5 reusable classic laryngeal mask airway. METHODS: Two hundred and three ASA I and II children undergoing elective cataract surgery requiring general anesthesia receiving laryngeal mask airway sizes 1-2.5 were recruited to this study. The laryngeal mask airway was placed using standard technique. After insertion of laryngeal mask airway, the cuff was slowly inflated until a slight outward shift of device was noted. Cuff pressures were measured using calibrated hand held Portex Cuff Inflator Pressure Gauge (Portex Limited, Hythe, Kent, UK). If the cuff pressure was >60 cm H(2)O, the cuff was deflated to achieve a cuff pressure of 55-60 cm H(2)O. The volume of air required to achieve this pressure was recorded. RESULTS: The volume of air required to achieve the pressure between 55 and 60 cm H(2)O in laryngeal mask airway size 1, 1.5, 2.0, and 2.5 were 2.750 ± 0.2565, 4.951 ± 0.5378, 6.927 ± 0.6328, and 10.208 ± 1.4535 ml, respectively. The difference between the initial and the final cuff volumes and pressures in all laryngeal mask airway sizes were statistically significant(P = 0.000). CONCLUSION: Lower cuff volumes are required to achieve a pressure of 60 cm H(2)O than those required if clinical end points are used as a sole guide for determining cuff inflation for patients receiving pediatric laryngeal mask airways.