Ultrasound: A novel alternative technique for cervical epidural space visualization-A pilot study.

Background: Neuraxial ultrasound (US), a newer modality, can be used for neuraxial imaging, helping in visualizing and aiding in epidural space catheterization. The aim of this study was to evaluate the efficacy of the US for cervical epidural access and to determine the failure rate and complication associated with this technique. Methods: A prospective single-arm pilot study was conducted on 21 participants. The neuraxial US image quality assessment by Ultrasound Visibility Score (UVS), epidural space depth measurement by US and by conventional loss of resistance (LOR) technique, and post-procedure epidural catheter confirmation by real-time US were the study parameters. Any procedural complications or failure rate were recorded. The Kolmogorov-Smirnov test, paired-samples t-test, and Chi-square test were used for the statistical comparison. Results: The pre-procedural UVS by the transverse interlaminar view (x/21) was 2.81 ± 1.94 and by the oblique paramedian sagittal view was 16.66 ± 2.39 with UVS being best in the paramedian oblique sagittal view (P- value < 0.05). The comparison of depth of the epidural space identified by USG and that by the LOR technique was statistically insignificant (P = 0.83). The average puncture attempts were 1.1 ± 0.3. Post-procedure US epidural catheter confirmation score (x/3) was 1.44 ± 0.44 with either epidural space expansion or microbubbles seen or both. Conclusion: The pilot study has successfully demonstrated the implication of US for visualizing and aiding in epidural space catheterization. Also, the failure rate and procedural complications were drastically minimized with the help of US as compared to the traditional blind technique.

Serum Cortisol Levels with Etomidate Induction: A Speculation That Needs To Be Reviewed.

Context: Hemodynamic stability during induction of anesthesia is always a concern for an anesthesiologist. Propofol remains the most popular induction agent with its favorable characteristics and few drawbacks like decrease in heart rate and blood pressure (BP). Although etomidate provides better hemodynamic stability, its use declined due to reports of adrenocortical suppression. Aims: We designed a study to compare the effect of anesthetic induction with etomidate versus propofol on serum cortisol levels and hemodynamics. Settings and Design: This was a prospective randomized double-blind comparative study. Subjects and Methods: Sixty ASA PS classes I and II patients scheduled for laparoscopic inguinal hernia repair under general anesthesia were included in the study. Thirty patients received propofol 2 mg.kg-1 and thirty, etomidate 0.3 mg.kg-1. Blood samples for serum cortisol were withdrawn preoperatively, immediate postoperatively, and 24 h after surgery. Vitals were monitored throughout. Statistical Analysis Used: All data are presented as mean ± standard deviation and proportions. Demographic data were analyzed by Student's t-test, and Chi-square test was used to analyze changes over time. The statistical software SPSS version 25.0 was used for data analysis. Results: Systolic blood pressure (BP), diastolic BP, and mean BP were more stable in the etomidate group compared to the propofol group. Serum cortisol levels before surgery in both the groups were within normal limits and comparable, followed by a significant decline in the etomidate group and rise in the propofol group in the immediate postoperative period. The levels in the third sample were comparable in both the groups. Conclusion: Etomidate offers superior hemodynamic compared to propofol. A decrease in serum cortisol level in the etomidate group was transient returning back to normal within 24 h.