An Update on Initial Epidemiological Profile, Clinical Course, and Outcome of COVID-19 Patients at a Tertiary Care Center in India.

BACKGROUND AND AIM: Coronavirus disease 2019 (COVID-19) has become a global pandemic with the spectrum of disease from asymptomatic or mild disease to severe cases requiring intensive care unit (ICU) admission. In India, it started with milder presentation affecting younger population. Later on, an increase in disease severity was observed involving older age group as well. However, there is a paucity of published data regarding patients requiring ICU care in India. This case series describes the initial experience of an ICU in India regarding epidemiological profile, clinical course, and outcome of critically ill COVID-19 patients. METHODS: This case series included 27 consecutive laboratory-confirmed COVID-19 patients who were admitted in a tertiary care ICU over 14 days period, followed up till their discharge from ICU. Demographic and clinical data, including laboratory and radiological findings, were compiled with special attention to co-morbidities of the patients. The management of these patients was done as per the institutional protocol for critically ill COVID-19 patients. RESULTS: The median age of the patients was 50 years with no difference in gender. Comorbid conditions were seen in 85% of the patients with diabetes (43.7%) and hypertension (37.5%) as the most common conditions. The median duration of symptoms before admission was 6 days with fever as the most common clinical symptom at presentation. Chest roentogram showed bilateral lung infiltrates in 88.8% of the patients. Mild, moderate, and severe hypoxia were observed in 3, 8, and 16 patients, respectively. Ten patients were managed with oxygen therapy. Seventeen patients (62.9%) required ventilatory support. Mortality rate among patients admitted to our ICU was 59.2%. CONCLUSIONS: This case series shows middle-aged patients with comorbid diseases present with severe COVID-19 disease and have poor outcome.

Hemodynamic, Airway Pressure, and Capnometric Changes and Perioperative Outcome in Pediatric Laparoscopic Inguinal Herniorrhaphy: A Comparison with Open Inguinal Herniorrhaphy.

BACKGROUND: Laparoscopic procedures which are now established in pediatric population as well exposes the child to supplemental cardiorespiratory changes due to increase in intraabdominal pressure (IAP) and hypercarbia. AIMS: This study aims to analyze the effects of pneumoperitoneum and postural modifications on cardiorespiratory system (primary outcome) during pediatric laparoscopic herniorrhaphy (LH) and its comparison with open herniorrhaphy (OH) and assessment of overall perioperative outcome (secondary outcome). SETTINGS AND DESIGN: A prospective, observational study conducted in a tertiary care hospital. MATERIALS AND METHODS: Fifty children undergoing either LH (n = 25) or OH (n = 25) were included in the study. Anesthetic procedure was standardized. Parameters monitored were heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressures (MAP), electrocardiogram lead-II, end-tidal CO2 (ETCO2), airway pressures PPeak, PPlateau, PMean, pulse oximetry, IAP, minute ventilation/respiratory rate alterations. STATISTICAL ANALYSIS USED: Student's t-test and Chi-square test were applied to compare different variables between the two groups. Intragroup analysis was done using the analysis of variance test. RESULTS: The HR was comparable in both groups. The rise in SBP, DBP, and MAP was 9% (102.88 ± 6.91-121.32 ± 6.63), 19% (60.88 ± 4.94-77.00 ± 9.75), and 14.8% (73.92 ± 4.65-90.40 ± 8.42), respectively, in group LH. The rise in peak, plateau, and mean airway pressures was 19.4% (14.20 ± 2.00-18.00 ± 2.54), 20.1% (13.32 ± 1.89-16.89 ± 2.60), and 16.1% (6.20 ± 1.00-7.47 ± 0.96), respectively, in group LH. ETCO2 showed a maximum rise of 19.4% (34.52 ± 3.61-41.21 ± 3.99) in group LH. In laparoscopic group, recurrence was seen in 3 patients. CONCLUSIONS: We found significant hemodynamic, airway pressure, and capnometric changes during pediatric LH with comparable perioperative outcome among the two groups.

Smoke Inhalation Injury: Etiopathogenesis, Diagnosis, and Management.

Smoke inhalation injury is a major determinant of morbidity and mortality in fire victims. It is a complex multifaceted injury affecting initially the airway; however, in short time, it can become a complex life-threatening systemic disease affecting every organ in the body. In this review, we provide a summary of the underlying pathophysiology of organ dysfunction and provide an up-to-date survey of the various critical care modalities that have been found beneficial in caring for these patients. Major pathophysiological change is development of edema in the respiratory tract. The tracheobronchial tree is injured by steam and toxic chemicals, leading to bronchoconstriction. Lung parenchyma is damaged by the release of proteolytic elastases, leading to release of inflammatory mediators, increase in transvascular flux of fluids, and development of pulmonary edema and atelectasis. Decreased levels of surfactant and immunomodulators such as interleukins and tumor-necrosis-factor-α accentuate the injury. A primary survey is conducted at the site of fire, to ensure adequate airway, breathing, and circulation. A good intravenous access is obtained for the administration of resuscitation fluids. Early intubation, preferably with fiberoptic bronchoscope, is prudent before development of airway edema. Bronchial hygiene is maintained, which involves therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation. Pharmacological agents such as beta-2 agonists, racemic epinephrine, N-acetyl cysteine, and aerosolized heparin are used for improving oxygenation of lungs. Newer agents being tested are perfluorohexane, porcine pulmonary surfactant, and ClearMate. Early diagnosis and treatment of smoke inhalation injury are the keys for better outcome.

Comparison of the Efficacy of Intrathecal Isobaric Ropivacaine and Bupivacaine in Day Care Knee Arthroscopy: A Randomized Controlled Trial.

BACKGROUND: The primary goal of ambulatory anesthesia is a rapid recovery with minimal side effects. Ropivacaine, due to its property of sensory-motor dissociation, maybe a useful agent when equivalent spinal anesthesia and quicker recovery of motor function is desirable. AIM: The aim of this study is to compare the efficacy of intrathecal isobaric ropivacaine with bupivacaine and to assess their postoperative recovery profile in patients undergoing arthroscopic knee surgery. SETTING AND DESIGN: This randomized controlled study was conducted at a tertiary care hospital. MATERIALS AND METHODS: A total of 90 adult American Society of Anaesthesiologist physical status Classes 1 and 2 patients were randomized into two groups to receive 2 ml plain solution of either 0.5% bupivacaine (Group B) or 0.75% ropivacaine (Group R). In the intraoperative period, onset, efficacy, duration, and regression of sensory and motor block were noted in both the groups at regular intervals. Postoperatively, the groups were compared for pain score, recovery profile, analgesic requirement, and complications. STATISTICAL ANALYSIS: Data analysis was performed using Chi-square test and Student's t-test. RESULTS: The mean onset time of sensory block at L1 was significantly less (P = 0.025) and duration of sensory and motor block was significantly more (P = 0.001) with bupivacaine as compared to ropivacaine. The analgesic requirement on the 1st postoperative day (P = 0.011) and incidence of delayed voiding of urine (P = 0.022) were significantly more with ropivacaine. The postoperative recovery profile and discharge times were similar between the groups. CONCLUSION: Isobaric ropivacaine was associated with a longer onset and shorter duration of sensory and motor block, increased postoperative analgesic requirement, higher complication rate, and similar discharge times as compared with bupivacaine. Therefore, isobaric bupivacaine may be preferred over isobaric ropivacaine for day care knee arthroscopy, especially in cases with an anticipated longer duration of surgery.

Evaluation of the efficacy of desflurane with or without labetalol for hypotensive anesthesia in middle ear microsurgery.

BACKGROUND AND AIMS: Hypotensive anesthesia technique is used to reduce intraoperative bleeding and to improve the visibility of the operative field. The aim was to evaluate the efficacy of desflurane with and without labetalol for producing hypotensive anesthesia. MATERIAL AND METHODS: Sixty adult patients undergoing elective middle ear surgery were administered general anesthesia and randomly divided into two groups - Group D and Group L. The target mean arterial pressure (MAP) was 55-65 mmHg during hypotensive period. Group D patients received an increasing concentration of desflurane alone. Group L patients received 3% desflurane plus labetalol (loading dose 0.3 mg/kg intravenously, followed by 10 mg increments every 10 min). Student's t-test and paired t-test were used to compare the hemodynamic parameters. Visibility of the operative field, anesthetic and rescue drug requirement, partial pressure of oxygen in arterial blood, time taken for induction and reversal of hypotension and recovery characteristics were noted. RESULTS: Target MAP was achieved in both the groups. Group D was associated with a higher mean heart rate compared with Group L (77.3 ± 11.0/min vs. 70.5 ± 2.5/min, respectively; P < 0.001) during the hypotensive period, along with a higher requirement for desflurane (P = 0.000) and metoprolol (P = 0.01). Time taken to achieve target MAP was lesser in Group L compared with Group D (33.7 ± 7.1 vs. 39.8 ± 6.2 min, respectively; P = 0.000). Time taken to return to baseline MAP was faster in Group D (P = 0.03). Emergence time was longer with desflurane alone (P = 0.000) resulting in greater sedation (P = 0.000) in the immediate postoperative period. CONCLUSION: Although desflurane is effective for inducing deliberate hypotension in middle ear microsurgery, the combination of desflurane with labetalol is associated with decreased requirement of desflurane, absence of reflex tachycardia, faster induction of hypotension, faster recovery from anesthesia, and less postoperative sedation.

Sternomental distance and sternomental displacement as predictors of difficult laryngoscopy and intubation in adult patients.

BACKGROUND: Several morphometric airway measurements have been used to predict difficult laryngoscopy (DL). This study evaluated sternomental distance (SMD) and sternomental displacement (SMDD, difference between SMD measured in neutral and extended head position), as predictors of DL and difficult intubation (DI). MATERIALS AND METHODS: We studied 610 adult patients scheduled to receive general anesthesia with tracheal intubation. SMD, SMDD, physical, and airway characteristics were measured. DL (Cormack-Lehane grade 3/4) and DI (assessed by Intubation Difficulty Scale) were evaluated. The optimal cut-off points for SMD and SMDD were identified by using receiver operating characteristic (ROC) analysis. Multivariate logistic regression was used to predict DL and ROC curve was used to assess accuracy on developed regression model. RESULTS: The incidence of DL and DI was 15.4% and 8.3%, respectively. The cut-off values for SMD and SMDD were ≤14.75 cm (sensitivity 66%, specificity 60%) and ≤5.25 cm (sensitivity 70%, specificity 53%), respectively, for predicting DL. The area under the curve (AUC) with 95% confidence interval (CI) for SMD was 0.66 (0.60-0.72) and that for SMDD was 0.687 (0.63-0.74). Multivariate analysis with logistic regression identified inter-incisor distance, neck movement <80°, SMD, SMDD, short neck and history of snoring as predictors and the predictive model so obtained exhibited a higher diagnostic accuracy (AUC: 0.82; 95% CI 0.77-0.86). SMDD, but not SMD, correlated with DI. CONCLUSIONS: Both SMD and SMDD provide a rapid, simple, objective test that may help identifying patients at risk of DL. Their predictive value improves considerably when combined with the other predictors identified by logistic regression.

Attenuation of the hemodynamic response to laryngoscopy and tracheal intubation with fentanyl, lignocaine nebulization, and a combination of both: A randomized controlled trial.

BACKGROUND: The present study was undertaken to compare and evaluate the efficacy of intravenous (IV) fentanyl and lignocaine airway nebulization and a combination of both in attenuating the hemodynamic response to laryngoscopy and tracheal intubation. MATERIALS AND METHODS: Ninety-six patients of either sex aged between 18 and 65 years of age, belonging to the American Society of Anesthesiologists (ASA) health status Classes I and II, undergoing elective surgery requiring general anesthesia with endotracheal intubation were included in the study. Patients were randomly divided into three groups. Group F received IV fentanyl 2 µg/kg, Group L received nebulization with 3 mg/kg of 4% lignocaine, and Group FL received both nebulization with 3 mg/kg of 4% lignocaine and IV fentanyl 2 µg/kg before intubation. Hemodynamic parameters were noted before and immediately after induction, 1 min after intubation, and every minute after intubation for 10 min. RESULTS: Hemodynamic response to laryngoscopy and intubation was not completely abolished in any of the groups. Nebulized lignocaine was least effective in attenuating hemodynamic response to intubation, and hemodynamic parameters were significantly high after intubation as compared to other groups. Fentanyl alone or in combination with nebulized lignocaine was most effective, and Group F and Group FL were comparable. The maximum increase in mean blood pressure after intubation from baseline in Groups F, L, and FL was 7.4%, 14.6%, and 5.4%, respectively. CONCLUSION: In our study, IV fentanyl 2 µg/kg administered 5 min before induction was found to be the most effective in attenuating the hemodynamic response. There was no advantage to the use of nebulized lignocaine in attenuating the hemodynamic response to laryngoscopy and intubation.

Variability in plasma concentration of cefotaxime in critically ill patients in an Intensive Care Unit of India and its pharmacodynamic outcome: A nonrandomized, prospective, open-label, analytical study.

BACKGROUND: Cefotaxime is a widely utilized cephalosporin in most intensive care units of India. However, no data are available about its pharmacokinetic/pharmacodynamic variability in critically ill patients of the Indian population. AIM: To investigate the variability in the plasma concentration and pharmacodynamic profile of intermittent dosing of cefotaxime in critically ill patients, according to their locus of infection and causative organism. MATERIALS AND METHODS: Cefotaxime levels were determined using high-performance liquid chromatography by grouping patients according to their locus of infection as hepatobiliary, renal, pulmonary, and others. Patients with cefotaxime concentration below the minimum inhibitory concentration (MIC) and 5 times below the MIC for the isolated organism were determined. RESULTS: The difference in the plasma cefotaxime concentration between the hepatobiliary and the nonhepatobiliary groups was significant at 1 h (P = 0.02) following drug dosing, while the difference was significant between the renal and nonrenal group at 1 h (P = 0.001), 4 h (P = 0.009), and 8 h (P = 0.02) after drug dosing. The pulmonary group showed significantly (P < 0.05) lower plasma cefotaxime levels than the nonpulmonary group at all-time points. The cefotaxime levels were below the MIC and below 5 times the MIC for the isolated organism in 16.67% and 43.33% of the patients, respectively. CONCLUSION: The concentration of cefotaxime differs according to the locus of an infection in critically ill patients. Use of another class of antibiotic or shifting to continuous dosing of cefotaxime, for organisms having MIC values above 1 mg/L, is advisable due to the fear of resistance.

Clinical evaluation of post-operative analgesia comparing suprascapular nerve block and interscalene brachial plexus block in patients undergoing shoulder arthroscopic surgery.

BACKGROUND: Shoulder arthroscopic surgeries have a high incidence of severe post-operative pain significant enough to interfere with recovery and rehabilitation. A regional anaesthetic technique combined with general anaesthesia reduces intra-operative requirements of anaesthesia and provides a better post-operative pain relief. As the commonly employed technique of interscalene brachial plexus block (ISB) is associated with potential serious complications, suprascapular nerve block (SSB) can be used as a safer alternative. METHODS AND MATERIAL: In this prospective study, 60 ASA 1 or 2 adult patients undergoing shoulder arthroscopic surgery were randomised into two groups - ISB and SSB. In group ISB, ISB with 20 ml of 0.5% bupivacaine mixed with 75 µg clonidine was given. In the SSB group SSB was given with 15 ml of 0.5% bupivacaine with 75 µg clonidine. Pain was assessed using visual analogue scale and verbal pain scale scores and time to first rescue analgesia was noted. We used Student's t test and Chi-square/Fisher Exact test and used a statistical software to compare data. RESULTS: In the present study, the mean duration of analgesia was 2.53 ± 2.26 h in SSB group compared to 7.23 ± 6.83 h in group ISB (p value < 0.05). Overall rescue analgesic requirements were higher in SSB group compared to ISB group (63.3% versus 40.0%) but this was statistically not significant (p value > 0.05). CONCLUSION: Both interscalene and SSB can be used to provide intra-operative and post-operative analgesia in patients undergoing shoulder arthroscopy.

Pharmacokinetic/pharmacodynamic profiling of imipenem in patients admitted to an intensive care unit in India: A nonrandomized, cross-sectional, analytical, open-labeled study.

BACKGROUND AND AIM: Widespread use of imipenem in intensive care units (ICUs) in India has led to the development of numerous carbapenemase-producing strains of pathogens. The altered pathophysiological state in critically ill patients could lead to subtherapeutic antibiotic levels. Hence, the aim of this study was to investigate the variability in the pharmacokinetic and pharmacodynamic profile of imipenem in critically ill patients admitted to an ICU in India. MATERIALS AND METHODS: Plasma concentration of imipenem was determined in critically ill patients using high performance liquid chromatography, at different time points, by grouping them according to their locus of infection. The elimination half-life (t΍) and volume of distribution (Vd) values were also computed. The patients with imipenem trough concentration values below the minimum inhibitory concentration (MIC) and 5 times the MIC for the isolated pathogen were determined. RESULTS: The difference in the plasma imipenem concentration between the gastrointestinal and the nongastrointestinal groups was significant at 2 h (P = 0.015) following drug dosing; while the difference was significant between the skin/cellulitis and nonskin/cellulitus groups at 2 h (P = 0.008), after drug dosing. The imipenem levels were above the MIC and 5 times the MIC for the isolated organism in 96.67% and 50% of the patients, respectively. CONCLUSIONS: The pharmacokinetic profile of imipenem does not vary according to the locus of an infection in critically ill patients. Imipenem, 3 g/day intermittent dosing, maintains a plasma concentration which is adequate to treat most infections encountered in patients admitted to an ICU. However, a change in the dosing regimen is suggested for patients infected with organisms having MIC values above 4 mg/L.

Stellate ganglion block can relieve symptoms and pain and prevent facial nerve damage.

Ramsay hunt syndrome[1] is a varicella zoster virus infection of the geniculate ganglion of the facial nerve. It is typically associated with a red rash and blister (inflamed vesicles or tiny water filled sacks in the skin) in or around the ear and eardrum and sometimes on the roof of the mouth or tongue. Corticosteroid, oral acyclovir, and anticonvulsant are used for treatment of this. In addition to this sympathetic neural blockade via stellate ganglion block is used to prevent facial nerve damage and relieve symptoms. We present a case of Ramsay hunt syndrome in which pain and symptoms are not relieved by oral medication but by daily sittings of stellate ganglion block with local anesthetic and steroid, pain, and other symptoms are relieved, and facial nerve damage is prevented.

A prospective, randomized, double-blind study to compare the efficacy of lidocaine + metoclopramide and lidocaine + ketamine combinations in preventing pain on propofol injection.

PURPOSE: Propofol injection is known to cause distressing pain, and various methods have been used to decrease this pain. We investigated the efficacy of the lidocaine + metoclopramide and lidocaine + ketamine combinations on modulating propofol injection pain. METHODS: Ninety ASA I/II patients aged 20-60 years were randomly assigned to three groups to receive lidocaine 20 mg (group L), lidocaine 20 mg + metoclopramide 10 mg (group LM), or lidocaine 20 mg + ketamine 5 mg (group LK), respectively, with venous occlusion for 1 min using a forearm tourniquet. Propofol 0.5 mg/kg was subsequently administered into a dorsal hand vein, and pain was assessed during its injection using a verbal rating score. The results were analyzed statistically with analysis of variance, the chi-square test, and the Wilcoxon rank sum test, where appropriate. The significance level was set at p < 0.05. RESULTS: The incidence of pain was rated to be significantly less in patients in groups LM (40 %) and LK (6.7 %) than in those in group L (83.3 %) (p = 0.001 and p < 0.001, respectively). The pain score [median (range)] was also significantly less in patients in groups LM [0 (0-3)] and LK [0 (0-2)] than in those in group L [2 (0-3)] (p = 0.001 for both groups). CONCLUSION: The lidocaine-ketamine combination is most effective for decreasing the pain on propofol injection.

Difficult laryngoscopy and intubation in the Indian population: An assessment of anatomical and clinical risk factors.

BACKGROUND AND AIM: Differences in patient characteristics due to race or ethnicity may influence the incidence of difficult airway. Our purpose was to determine the incidence of difficult laryngoscopy and intubation, as well as the anatomical features and clinical risk factors that influence them, in the Indian population. METHODS: In 330 adult patients receiving general anaesthesia with tracheal intubation, airway characteristics and clinical factors were determined and their association with difficult laryngoscopy (Cormack and Lehane grade 3 and 4) was analysed. Intubation Difficulty Scale score was used to identify degree of difficult laryngoscopy. RESULTS: The incidence of difficult laryngoscopy and intubation was 9.7% and 4.5%, respectively. Univariate analysis showed that increasing age and weight, male gender, modified Mallampati class (MMC) 3 and 4 in sitting and supine positions, inter-incisor distance (IID) ≤3.5 cm, thyromental (TMD) and sternomental distance, ratio of height and TMD, short neck, limited mandibular protrusion, decreased range of neck movement, history of snoring, receding mandible and cervical spondylosis were associated with difficult laryngoscopy. Multivariate analysis identified four variables that were independently associated with difficult laryngoscopy: MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring. CONCLUSIONS: We found an incidence of 9.7% and 4.5% for difficult laryngoscopy and difficult intubation, respectively, in Indian patients with apparently normal airways. MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring were independently related to difficult laryngoscopy. There was a high incidence (48.5%) of minor difficulty in intubation.

Cardiac dysrhythmia complicating total parotidectomy.

Sudden severe dysrhythmias during anaesthesia can be life- threatening for the patient. We describe a case in which ventricular dysrhythmias and severe bradycardia occurred during dissection and mobilization of the deep lobe of the parotid gland during total parotidectomy under general anaesthesia. We believe that these dysrhythmias were caused by a trigemino- vagal reflex similar to the oculocardiac reflex, but with afferent innervation from mandibular division of the trigeminal nerve. The case report is presented to illustrate a possible existence and importance of reflex bradycardic responses that may occur during surgical procedures involving the parotid gland.

Intubating conditions following rapid sequence induction with three doses of succinylcholine.

BACKGROUND: The aim of this prospective, randomized, double-blind study was to compare tracheal intubating conditions and the duration of apnoea following administration of 0.4, 0.6 and 1.0 mg/kg of succinylcholine during simulated rapid sequence induction of anaesthesia. METHODS: Anaesthesia was induced with fentanyl 2 µg/kg and propofol 2 mg/kg followed by application of cricoid pressure. Patients were randomly allocated to three groups according to the dose of succinylcholine administered (0.4, 0.6 or 1.0 mg/kg). Intubating conditions were assessed at 60 s after succinylcholine administration. Time to first diaphragmatic contraction (apnoea time) and time to resumption of regular spontaneous breathing were noted. RESULTS: Excellent intubating conditions were obtained in 52.4%, 95.7% and 100% of the patients after 0.4, 0.6 and 1.0 mg/kg succinylcholine, respectively; P<0.001. Acceptable intubating conditions (excellent and good grade combined) were obtained in 66.7%, 100% and 100% of the patients after 0.4, 0.6 and 1.0 mg/ kg succinylcholine, respectively; P<0.001. Apnoea time and resumption of regular spontaneous breathing were dose-dependent. Apnoea time was 3.8±1.1 min, 4.3±0.9 min and 8.2±3.4 min in groups 0.4, 0.6 and 1.0 mg/kg, respectively; P<0.001. Time to regular spontaneous breathing was 5.3±1.2 min, 5.5±1.1 min and 8.9±3.5 min in groups 0.4, 0.6 and 1.0 mg/kg, respectively; P<0.001. CONCLUSION: A dose of 0.6 mg/kg succinylcholine can be used for rapid sequence induction of anaesthesia as it provides acceptable intubating conditions with a shorter apnoea time compared with a dose of 1 mg/kg.

Negative-pressure pulmonary oedema in a patient undergoing shoulder arthroscopy.

An 18-year-old ASA-I patient who underwent elective left shoulder arthroscopy developed severe airway obstruction post-extubation due to fluid extravasation from the shoulder joint into the neck and airway tissue. Re-intubation for relief of obstruction resulted in negative-pressure pulmonary oedema. The patient was electively ventilated in the intensive care unit and recovered uneventfully. A high index of suspicion along with monitoring of neck circumference can prevent this kind of complication.

The effect of injection speed on the spinal block characteristics of hyperbaric bupivacaine 0.5% in the elderly.

PURPOSE: The purpose of this prospective, randomized, double-blind study was to compare anesthetic characteristics after two speeds of intrathecal injection of hyperbaric bupivacaine in elderly patients. METHODS: Fifty-six patients, aged ≥65 years, undergoing transurethral surgery under spinal anesthesia were allocated randomly to two groups according to rate of intrathecal injection of 2 ml hyperbaric bupivacaine 0.5%: group Fast (maximum possible rate; mean 0.38 ml/s) n = 26; group Slow (over 40 s; 0.05 ml/s), n = 25. Spinal blocks were administered in the lateral position. Data collection at different times included sensory level, motor block, hemodynamic changes, and occurrence of neurological symptoms. RESULTS: There was no significant difference between the groups regarding maximum sensory anesthetic level achieved (group Fast: T7 (T4-T10), median (range); group Slow T8 (T6-T10), P = 0.184); times (min) to reach (a) T10 sensory level (group Fast 5.3 ± 4.2 (mean ± SD), group Slow 8.0 ± 6.5, P = 0.093); (b) maximum sensory level (group Fast 11.6 ± 4.7; group Slow 13.6 ± 6.1, P = 0.199); and (c) 2-segment regression of anesthesia (group Fast 92.2 ± 29.6; group Slow 104.7 ± 36.1, P = 0.182). Degree and duration of motor block were similar (P = 0.947 and P = 0.895, respectively). Hemodynamic changes, ephedrine and atropine requirement, incidence of postoperative neurological symptoms after 24 h and 1 week were similar (all P > 0.05). CONCLUSIONS: An eightfold difference in speed of intrathecal injection of 0.5% hyperbaric bupivacaine did not affect the clinical characteristics of spinal anesthesia in elderly patients undergoing transurethral surgery.

Comparison of 'whoosh' and modified 'swoosh' test for identification of the caudal epidural space in children.

BACKGROUND: Caudal analgesia is widely used in pediatric anesthesia practice. The 'whoosh' test which uses air to identify the epidural space, has been recommended as a guide for successful needle placement. However, the use of air may be associated with an incidence of neurological complications. The 'swoosh' test avoids the injection of air and was originally performed using injection of a local anesthetic solution. A comparison was made between the 'whoosh' test and a modified 'swoosh' test using saline to identify the caudal epidural space in children. METHODS: We studied 60 children of either sex in the age group of 2-8 years undergoing inguinal herniotomy. During insertion of the caudal block, a stethoscope was placed over the lower lumbar spine to note the presence or absence of 'whoosh' or 'swoosh', by an independent observer who was blinded to the injection of 1 ml of air or saline which was given simultaneously by the operator into the caudal space. The operator's clinical impression of successful insertion of the needle was also recorded and correlated with the presence or absence of 'whoosh' or 'swoosh'. In addition, the need for supplemental intraoperative analgesia was noted. RESULTS: Overall success rate of caudal block using the 'whoosh' and modified 'swoosh' tests was found to be 96.6% and 93.3%, respectively as judged by the lack of supplementary perioperative analgesia. The sensitivity, specificity and positive predictive value of the 'whoosh' test and clinical predictors of caudal placement was found to be 100% whereas the modified 'swoosh' test had a sensitivity of 93%, specificity of 50% and a positive predictive value of 96%. However, statistically there was no significant difference between the clinical predictors, 'whoosh' and the modified 'swoosh' test for identification of the caudal epidural space. CONCLUSIONS: The modified 'swoosh' test is as reliable as the 'whoosh' test and we recommend it for identification of the caudal epidural space in children as it avoids injection of air into the caudal space.