Safety and efficacy of video DLT (VDLT) for lung isolation during the COVID-19 pandemic.

One lung ventilation (OLV) with collapse of the ipsilateral lung is a prerequisite for most thoracic surgical procedures. Double-lumen tube (DLT) is still the preferred method to isolate the lungs and fiberoptic bronchoscopy (FOB) is the gold standard for the confirmation of correct placement of the DLT. However, both these procedures are considered as a high-aerosol-generating procedures and are hazardous to the health workers, particularly at this time of the COVID-19 pandemic. We did nine thoracic surgery cases categorized as essential, requiring OLV during the ongoing period of the COVID-19 between April 2020 and May 2020 where we used Full view DLT for lung isolation. We present our case series which shows that the Full view VDLT can minimize or circumvent the use of FOB during OLV, and reduce the time taken to isolate the lungs thus reducing aerosol in the theater. None of the nine patients required FOB for confirmation of initial positioning nor for diagnosis of intraoperative malposition. The time taken to isolate the lungs was significantly less and the surgical positioning was done under real-time monitoring by visualizing the blue cuff distal to carina at all times. The real-time monitoring by the Full view VDLT offers the additional advantage of detecting any malposition even before it results in loss of isolation or desaturation. We conclude that the Full view VDLT is an efficient and safe alternative for lung isolation at this time of the COVID-19 pandemic.

A randomized control trial to compare thoracic epidural with intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy.

Objective: The objective of the study is to compare the efficacy of Thoracic epidural with Intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy. Methodology and Design: This study is designed as a prospective randomized clinical trial. Setting: Christian Medical College Hospital, Vellore, India. Participants: Patients undergoing elective thoracic surgery through posterolateral thoracotomy. Intervention: In Group A (TEA) patients epidural catheter was inserted at T5-6 level before induction of GA and analgesia was activated using 0.25% of bupivacaine towards the end of the surgery, before chest closure and infusion of 0.1% bupivacaine with 2 mcg/ml of fentanyl was started. In Group B (ICN) patients, an intercostal blockade of the 5 intercostal spaces was performed by the surgeon just before chest closure using 0.25% bupivacaine and a continuous intravenous morphine infusion of 0.015-0.02 mg/kg/hr was started. Measurements: Assessment of resting and dynamic pain intensity using Numerical rating scale and sedation using Ramsay sedation scale was done and recorded at 1, 6,12,18,24 hours during the first postoperative day. The other parameters that were measured include side effects and the requirement of rescue analgesia. Results: Resting and Dynamic (NRS) pain scores were less in Group A (TEA) than Group B (ICN). In the first 12 hours, the differences in both the resting (P = 0.0505) and dynamic (P = 0.0307) pain scores were statistically significant. By the end of the first postoperative day, sedation scores were more or less similar in both groups. The incidence of side effects and requirement of rescue analgesia were found to be similar in both the groups. Conclusion: To summarize, though the results show a slightly better quality of analgesia with the thoracic epidural, the difference being clinically insignificant intercostal blockade could be considered as a valid alternative.

The Effect of Change in Posture on Spirometry in Patients with Obstructive Sleep Apnoea Syndrome.

OBJECTIVES: Obstructive sleep apnoea syndrome (OSAS) is a growing health concern as it is associated with serious comorbidities. OSAS is mainly related to obesity, age, gender and a narrowed upper airway is commonly seen in patients with OSAS. This study aimed to compare spirometry parameters between obese OSAS patients and non-obese OSAS patients when patients moved from sitting to supine. METHODS: This cross-sectional study was conducted at Sultan Qaboos University Hospital, Muscat, Oman, between December 2009 and December 2010. Patients with severe OSAS and who were OSAS treatment naïve were recruited. Spirometry was performed in all patients in sitting and supine positions to assess forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC, forced expiratory flow (FEF) 50%, FEF 25-75%, maximum forced inspiratory flow and expiratory reserve volume. The mean difference in spirometry parameters between patients in sitting and supine positions was calculated. RESULTS: A total of 27 OSAS patients (19 males and 8 females) were included in this study. There was a significant difference in FEV1/FVC in obese and non-obese patients when changing position (P = 0.03). In addition, there was a significant change between male and female patients' FVC percentages (P <0.05). Male patients with OSAS had reduced FVC compared to females. There was no significant difference in the remaining spirometry parameters with patients' change of position. CONCLUSION: A supine position may cause lower airway obstruction in obese patients with OSAS. The reduced FVC in males possibly contributes to the high prevalence of OSAS in men compared to women.

A randomized controlled trial comparing the myocardial protective effects of isoflurane with propofol in patients undergoing elective coronary artery bypass surgery on cardiopulmonary bypass, assessed by changes in N-terminal brain natriuretic peptide.

OBJECTIVE: The objective of the study is to compare the myocardial protective effects of isoflurane with propofol in patients undergoing elective coronary artery bypass surgery on cardiopulmonary bypass (CPB), the cardio protection been assessed by changes in N-terminal brain natriuretic peptide (NT proBNP). Methodology and Design: This study is designed as a participant blinded, prospective randomized clinical trial. SETTING: Christian Medical College Hospital, Vellore, India. PARTICIPANTS: Patients undergoing elective coronary artery bypass surgery on CPB. INTERVENTION: Anesthesia was maintained with 0.8-1.2 end tidal concentrations of isoflurane in the isoflurane group and in the propofol group, anesthesia was maintained with propofol infusion as described by Roberts et al. MEASUREMENTS: Hemodynamic data were recorded at frequent intervals during the surgery and up to 24 h in the Intensive Care Unit (ICU). The other variables that were measured include duration of mechanical ventilation, dose and duration of inotropes in ICU, (inotrope score), duration of ICU stay, NT proBNP levels before induction and 24 h postoperatively, creatine kinase-MB levels in the immediate postoperative, first and second day. RESULTS: Mean heart rate was significantly higher in propofol group during sternotomy, (P = 0.021). Propofol group had a significantly more number of patients requiring nitroglycerine in the prebypass period (P = 0.01). The increase in NT proBNP from preoperative to postoperative value was lesser in the isoflurane group compared to propofol even though the difference was not statistically significant. The requirement of phenylephrine to maintain mean arterial pressure within 20% of baseline, mechanical ventilation duration, inotrope use, duration of ICU stay and hospital stay were found to be similar in both groups. CONCLUSION: Propofol exhibit comparable myocardial protective effect like that of isoflurane in patients undergoing coronary artery bypass graft surgery. Considering the unproven mortality benefit of isoflurane and the improved awareness of green OT concept, propofol may be the ideal alternative to volatile anesthetics, at least in patients with good left ventricular function.

Comparing the effects of oral clonidine premedication with intraoperative dexmedetomidine infusion on anesthetic requirement and recovery from anesthesia in patients undergoing major spine surgery.

BACKGROUND: Clonidine, an α2 agonist, has been used in anesthesia for many years to provide sedation, anxiolysis, analgesia, controlled hypotension, and to provide opioid-sparing anesthesia. Recently, there has been a great interest in using the newer α2 agonist, dexmedetomidine, because of its more selectivity toward α2 adrenoreceptors. We compared the effects of clonidine with dexmedetomidine on anesthetic requirement and recovery from anesthesia. METHODS: Seventy-four patients undergoing major spine surgery were randomly allocated to receive either oral clonidine premedication followed by an intraoperative saline infusion (group A) or placebo premedication followed by dexmedetomidine infusion in the intraoperative period (group B). Standard anesthesia protocols were followed for induction and maintenance. Heart rate, blood pressure, and end-tidal concentrations of isoflurane were noted every 15 minutes after proning. Hypertensive responses were treated with bolus doses of propofol and fentanyl. Hypotensive episodes were treated with bolus doses of ephedrine or phenylephrine. Primary outcomes were the comparisons of the effect of these 2 drugs on anesthetic requirement and recovery from anesthesia. Secondary outcomes were the comparisons of the hemodynamic response, intraoperative analgesic requirement, and blood loss during surgery. RESULTS: Demographic data, duration of surgery, total dose of fentanyl and propofol requirement, blood loss, and the recovery time were comparable between the 2 groups. Both drugs reduced the isoflurane requirement during surgery. However, the reduction was more and statistically significant with dexmedetomidine compared with clonidine group at 1 and 2 hours after proning (P=0.001, 0.039 at 1 and 2 h). Both drugs are equally effective in controlling the hemodynamics, and the number of episodes of hypotension, hypertension, and bradycardia were comparable between the 2 groups. CONCLUSIONS: Both clonidine and dexmedetomidine have anesthetic-sparing effect; however, it was more with dexmedetomidine than with clonidine. Recovery from isoflurane anesthesia was similar between both groups. Both are equally effective in controlling the hemodynamic response and reducing the blood loss during spine surgery.