Combined General and Epidural Anesthesia for Emergency Cesarean Delivery of Twins in a Parturient With Coarctation of Aorta.

Pregnancy is associated with increased coarctation-associated complications. We report the successful management of emergency lower-segment cesarean delivery in a patient with coarctation of aorta. A parturient at 34 weeks of gestation of a twin pregnancy with uncorrected coarctation of aorta was taken for emergency lower-segment cesarean delivery to be performed using epidural anesthesia. A mixture of lignocaine (lidocaine), bupivacaine, and fentanyl was administered epidurally. In view of unsatisfactory motor action, general anesthesia had to be administered. However, because of sufficient analgesia due to the epidural drugs, optimal hemodynamic control was achieved. A combination of general and epidural anesthesia minimizes adverse effects of coarctation of aorta, with improved maternal and fetal outcomes.

Comparison of continuous epidural infusion of 0.125% ropivacaine with 1 µg/ml fentanyl versus 0.125% bupivacaine with 1 µg/ml fentanyl for postoperative analgesia in major abdominal surgery.

BACKGROUND AND AIM: The present study was carried out to compare the efficacy of continuous epidural infusion of two amide local anesthetics, ropivacaine and bupivacaine with fentanyl for postoperative analgesia in major abdominal surgeries. MATERIAL AND METHODS: A total of 60 patients scheduled for major abdominal surgery were randomized into two study Groups B and R with thirty patients in each group. All patients were administered general anesthesia after placing epidural catheter. Patients received continuous epidural infusion of either 0.25% bupivacaine with 1 ug/ml fentanyl (Group B) or of 0.25% ropivacaine with 1 ug/ml fentanyl (Group R) at the rate 6 ml/h intraoperatively. Postoperatively, they received 0.125% bupivacaine with 1 ug/ml fentanyl (Group B) or 0.125% ropivacaine with 1 ug/ml fentanyl (Group R) at the rate 6 ml/h. Hemodynamic parameters, visual analog scale (VAS), level of sensory block, and degree of motor block (based on Bromage scale) were monitored for 24 h postoperatively. RESULTS: Hemodynamic parameters and VAS scores were comparable in the two groups. The level of sensory block was higher in bupivacaine group. There were more patients with higher Bromage score in the (23.3%) bupivacaine group than in (6.7%) ropivacaine group though the difference was not statistically significant. CONCLUSION: Both ropivacaine and bupivacaine in the concentration of 0.125% with fentanyl 1 ug/ml are equally safe, with minimal motor block and are effective in providing postoperative analgesia.

A prospective randomized controlled double-blind trial to assess the effects of dexmedetomidine during cleft palate surgery.

BACKGROUND: We investigated whether the intraoperative administration of dexmedetomidine would attenuate the profound sympathoadrenal response associated with cleft palate (CP) surgery. METHODS: Sixty children aged 6 months to 12 years undergoing CP surgery under general anesthesia were randomly assigned to the control (C) or dexmedetomidine (D) groups. Group C received benzodiazepine (0.05 mg/kg midazolam followed by infusion of normal saline) fentanyl isoflurane anesthesia, and Group D received dexmedetomidine (loading 1 µg/kg followed by infusion of 0.5 µg/kg/h) fentanyl isoflurane anesthesia. Heart rate (HR), mean blood pressure (MBP), intraoperative fentanyl and isoflurane requirements, recovery scores, emergence agitation, pain scores, time and requirement of rescue analgesic, and surgeon satisfaction were noted. RESULTS: Intraoperative HR and MBP in Group D were significantly lower than the corresponding values in Group C (P < 0.001). HR decreased up to 16% in Group D. By contrast, HR increased up to 20% in Group C. Group D had comparable MBP to its baseline, whereas Group C had higher MBP until extubation (P = 0.015). Two children in Group D developed bradycardia and hypotension, which was successfully treated. The fentanyl and isoflurane requirements decreased by 43% and 30%, respectively, in Group D patients compared to those in Group C (P < 0.001). Group D had lower pain scores and less emergence agitation (P < 0.001). Time until requirement of first rescue analgesic was longer in Group D than that in Group C (P < 0.001). Surgeon satisfaction was higher in Group D than that in Group C. CONCLUSIONS: Intravenous dexmedetomidine during CP surgery attenuated hemodynamic responses with excellent surgeon satisfaction. Close monitoring of hemodynamics is recommended.

A cohort evaluation of clinical use and performance characteristics of Ambu® AuraGain™: A prospective observational study.

BACKGROUND AND AIMS: Ambu® AuraGain™ (AG) (Ambu, Ballerup, Denmark) is a supraglottic device which has a design facilitating its use as a conduit for intubation. We designed this prospective observational study to assess the ease of AG placement in paralysed patients, determine its position and alignment to the glottis and assess its utility as a conduit for intubation. METHODS: One hundred patients, aged 18-60 years, American Society of Anesthesiologists physical status I-II, undergoing elective surgery under general anaesthesia were included in the study. The ease and number of attempts for successful insertion, ease of gastric tube insertion, leak pressures, fibre-optic grade of view, number of attempts and time for tracheal intubation, time for AG removal and complications were recorded. The mean, standard deviation (SD), interquartile range (IQR) and range were calculated. The upper limit of confidence interval for overall failure rate was calculated using Wilson's score method. RESULTS: AG was successfully inserted in all patients. The mean (SD) time taken for insertion was 17.32 (8.48) s. The median [IQR] leak pressures were 24 [20-28] cm of H2O. Optimal laryngeal view for intubation was obtained in 68 patients. Eighty-eight patients could be intubated in the first attempt. Five patients could not be intubated. The overall failure rate of device was 9%. CONCLUSION: AMBU® AuraGain™ serves as an effective ventilating aid, but caution is suggested before using it as a conduit for endotracheal intubation.

Is segmental epidural anaesthesia an optimal technique for patients undergoing percutaneous nephrolithotomy?

BACKGROUND AND AIMS: Neuraxial anaesthesia has recently become popular for percutaneous nephrolithotomy (PCNL). We conducted a study comparing general anaesthesia (GA) with segmental (T6-T12) epidural anaesthesia (SEA) for PCNL with respect to anaesthesia and surgical characteristics. METHODS: Ninety American Society of Anesthesiologists Physical Status-I and II patients undergoing PCNL randomly received either GA or SEA. Overall patient satisfaction was the primary end point. Intraoperative haemodynamics, epidural block characteristics, post-operative pain, time to rescue analgesic, total analgesic consumption, discharge times from post-anaesthesia care unit, surgeon satisfaction scores and stone clearance were secondary end points. Parametric data were analysed by Student's t-test while non-parametric data were compared with Mann-Whitney U-test. RESULTS: Group SEA reported better patient satisfaction (P = 0.005). Patients in group GA had significantly higher heart rates (P = 0.0001) and comparable mean arterial pressures (P = 0.24). Postoperatively, time to first rescue analgesic and total tramadol consumption was higher in Group GA (P = 0.001). Group SEA had lower pain scores (P = 0.001). Time to reach Aldrete's score of 9 was shorter in group SEA (P = 0.0001). The incidence of nausea was higher in group GA (P = 0.001); vomiting rates were comparable (P = 0.15). One patient in group SEA developed bradycardia which was successfully treated. Eight patients (18%) had hypertensive episodes in group GA versus none in group SEA (P = 0.0001). One patient in GA group had pleural injury and was managed with intercostal drain. Stone clearance and post-operative haemoglobin levels were comparable in both groups. CONCLUSION: PCNL under SEA has a role in selected patients, for short duration surgery and in expert hands.

Effect of Pneumoperitoneum and Lateral Position on Oropharyngeal Seal Pressures of Proseal LMA in Laparoscopic Urological Procedures.

INTRODUCTION: A sustained and effective oropharyngeal sealing with supraglottic airway is required to maintain the ventilation during laparoscopic surgery. Previous studies have observed the Oropharyngeal Seal Pressure (OSP) for Proseal Laryngeal Mask Airway (PLMA) after pneumoperitoneum in supine and trendelenburg position, where PLMA was found to be an effective airway device. This study was conducted with ProSeal LMA, for laparoscopic Urologic procedures done in lateral position. AIM: To measure OSP in supine and lateral position and to observe the effect of pneumoperitoneum in lateral position on OSP. Secondary objectives were to assess adequacy of ventilation and incidence of adverse events. MATERIALS AND METHODS: A total number of 25 patients of American Society of Anaesthesiologists (ASA) physical status II and I were enrolled. After induction of anaesthesia using a standardized protocol, PLMA was inserted. Ryle's tube was inserted through drain tube. The position of PLMA was confirmed with ease of insertion of Ryle's tube and fibreoptic grading of vocal cords. Patients were then put in lateral position. The OSP was measured in supine position. This value was baseline comparison for OSP in lateral position and that after pneumoperitoneum. We assessed the efficacy of PLMA for ventilation, after carboperitoneum in lateral position (peak airway pressure, End Tidal Carbon dioxide (EtCO2), SPO2). Incidence of adverse effects (displacement of device, gastric insufflation, regurgitation, coughing, sore throat, blood on device, trauma) was also noted. RESULTS: The OSP was above Peak Airway Pressure (PAP) in supine (22.1±5.4 and 15.4±4.49cm of H2O) and lateral position (22.6±5.3 and 16.1±4.6). After pneumoperitoneum, which was in lateral position, there was statistically significant (p-value <0.05) increase in both PAP (19.96±4.015) and OSP (24.32±4.98, p-value 0.03). There was no intraoperative displacement of PLMA. There was no event of suboptimal oxygenation. EtCO2 was always within normal limits. Gastric insufflation was present in one patient. One patient had coughing and blood was detected on device. Three patients had throat discomfort post-operatively. CONCLUSION: In this study, Oropharyngeal seal pressures with PLMA were found to increase after pneumoperitoneum in lateral position. PLMA forms an effective seal around airway and is an efficient and safe alternative for airway management in urological laparoscopic surgeries done in lateral position.

Successful management of a broken epidural catheter!!!

Breakage of epidural catheter though rare is a well-known but worrisome complication. Visualization of retained catheter is difficult even with modern radiological imaging techniques, and active surgical intervention might be necessary for removal of catheter fragment. We report such a case of breakage of an epidural catheter during its removal which led to surgical intervention.

Double blind comparison of combination of 0.1% ropivacaine and fentanyl to combination of 0.1% bupivacaine and fentanyl for extradural analgesia in labour.

BACKGROUND AND AIMS: Ropivacaine is considered as a safe alternative to bupivacaine for labor analgesia. The aim was to compare epidural ropivacaine and bupivacaine in intermittent doses for obstetric analgesia. MATERIAL AND METHODS: In this prospective, randomized, double-blind study, 60 women in labor were randomly allocated to receive either bupivacaine 0.1% with fentanyl 2 µg/mL (BF), or ropivacaine 0.1% with fentanyl 2 µg/mL (RF). Bromage scale, loss of cold sensation to ether swab in midclavicular line, visual analog scale were used to test for motor block, sensory block and pain, respectively. Hemodynamic parameters, onset of analgesia, dose requirement of drug to produce analgesia, duration of labor, and incidence of side effects were also recorded. Data were expressed as mean ± standard deviation and analyzed using students unpaired t-test, Chi-square and Mann-Whitney U-tests at P < 0.05. RESULTS: Both drugs were similar with respect to hemodynamic stability, onset of analgesia, quality of analgesia, sensory blockade, neonatal outcome, requirement of drugs, duration of labor, and incidence of side effects. Three parturient in bupivacaine (B-F) group had a motor block of Bromage 1 and were delivered using forceps. None of the parturient in ropivacaine (R-F) group had any motor block, and all had spontaneous vaginal delivery, but this difference was not statistically significant (P = 0.081). CONCLUSIONS: Bupivacaine and ropivacaine provide equivalent analgesia in low (0.1%) concentration.

I-gel versus laryngeal mask airway-Proseal: Comparison of two supraglottic airway devices in short surgical procedures.

BACKGROUND AND AIMS: Supraglottic airway devices have been established in clinical anesthesia practice and have been previously shown to be safe and efficient. The objective of this prospective, randomized trial was to compare I-Gel with LMA-Proseal in anesthetized spontaneously breathing patients. MATERIAL AND METHODS: Sixty patients undergoing short surgical procedures were randomly assigned to I-gel (Group I) or LMA- Proseal (Group P). Anesthesia was induced with standard doses of propofol and the supraglottic airway device was inserted. We compared the ease and time required for insertion, airway sealing pressure and adverse events. RESULTS: There were no significant differences in demographic and hemodynamic data. I-gel was significantly easier to insert than LMA-Proseal (P < 0.05) (Chi-square test). The mean time for insertion was more with Group P (41 + 09.41 secs) than with Group I (29.53 + 08.23 secs) (P < 0.05). Although the airway sealing pressure was significantly higher with Group P (25.73 + 02.21 cm of H2O), the airway sealing pressure of Group I (20.07 + 02.94 cm of H2O) was very well within normal limit (Student's t test). The success rate of first attempt insertion was more with Group I (P < 0.05). There was no evidence of airway trauma, regurgitation and aspiration. Sore throat was significantly more evident in Group P. CONCLUSION: I-Gel is a innovative supraglottic device with acceptable airway sealing pressure, easier to insert, less traumatic with lower incidence of sore throat. Hence I-Gel can be a good alternative to LMA-Proseal.

A prospective randomized double-blind study comparing dexmedetomidine vs. combination of midazolam-fentanyl for tympanoplasty surgery under monitored anesthesia care.

BACKGROUND: Analgesia and sedation are usually required for the comfort of the patient and surgeon during tympanoplasty surgery done under local anesthesia. In this study, satisfaction scores and effectiveness of sedation and analgesia with dexmedetomidine were compared with a combination of midazolam-fentanyl. MATERIALS AND METHODS: Ninety patients undergoing tympanoplasty under local anesthesia randomly received either IV dexmedetomidine 1 µg kg(-1) over 10 min followed by 0.2 µg kg(-1)h(-1) infusion (Group D) or IV midazolam 0.06 mg kg(-1) plus IV fentanyl 1 µg kg(-1) over 10 min (Group MF) followed by normal saline infusion at 0.2 ml kg(-1)h(-1). Sedation was titrated to Ramsay sedation score (RSS) of three. Vital parameters, rescue analgesics (fentanyl 1 µg kg(-1)) and sedatives (midazolam 0.01 mg kg(-1)), patient and surgeon satisfaction scores were recorded. RESULTS: Patient and surgeon satisfaction score was better in Group D than Group MF (median interquartile range (IQR) 9 (8-10) vs. 8 (6.5-9.5) and 9 (8.5-9.5) vs. 8 (6.75-9.25), P = 0.0001 for both). Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group MF (P < 0.05). Percentage of patients requiring rescue fentanyl was higher in Group MF than Group D (40% vs. 11.1%, P = 0.01). One patient in Group D while four in Group MF (8.8%) required rescue sedation with midazolam (P > 0.17). Seven patients in Group D had dry mouth vs. none in Group MF (P = 0.006). One patient in Group D had bradycardia with hypotension which was effectively treated. CONCLUSION: Dexmedetomidine is comparable to midazolam-fentanyl for sedation and analgesia in tympanoplasty with better surgeon and patient satisfaction. Hemodynamics need to be closely monitored.