The dexmedetomidine "augmented" sedato analgesic cocktail: An effective approach for sedation in prolonged endoscopic retrograde cholangio-pancreatography.

BACKGROUND AND AIMS: In absence of any published standard guideline for sedation or anesthesia practice for prolonged therapeutic "endoscopic retrograde cholangio-pancreatography (ERCP)", safe and cost-effective sedation protocol is the need of the hour. Our study aims to evaluate the efficacy of a dexmedetomidine as an add-on for prolonged deep sedation for ERCP and to compare three deep sedation regimens regarding safety and efficacy. MATERIAL AND METHODS: Forty-five consecutively enrolled patients planned for therapeutic ERCP and assumed to have prolonged procedural duration (>50 min) were divided into three groups in a randomized assessor blinded fashion. Group 1 received propofol and midazolam, Group 2 received the sedato-analgesic cocktail containing ketamine-propofol-midazolam-pentazocine, and the Group 3 received sedate-analgesic cocktail plus dexmedetomidine infusion under monitoring of vital parameters and according to the judgment of the concerned anesthesiologist. Total propofol requirement, episodes of gagging, oxygen desaturation, changes in mean blood pressure (MBP), recovery and satisfaction score of endoscopist, anesthetist and patient were noted and analyzed statistically using one way ANOVA with Bonferroni correction and Chi-square test. RESULTS: Mean propofol requirement, incidences of gagging and oxygen desaturation was significantly less in Group 2 and 3 compared to Group 1. MBP was more stable and recovery was faster in Group 3. Anesthetist's satisfaction was more with Group 2 and even more with Group 3. CONCLUSIONS: The sedato-analgesic cocktail was superior to the conventional propofol-midazolam regimen, dexmedetomidine as add-on increased the efficacy and safety of sedate-analgesic cocktail. It reduces propofol requirement, helps to maintain the patient in a safe and more stable level of sedation and increases satisfaction of the anesthetist.

Betahistine as an add-on: The magic bullet for postoperative nausea, vomiting and dizziness after middle ear surgery?

PURPOSE: Patients undergoing middle ear surgery experience variable degrees of postoperative nausea and vomiting (PONV) despite prophylaxis and treatment with ondansetron or other 5HT3 receptor antagonists. Furthermore vertigo or dizziness are not well controlled perioperatively. Role of betahistine was tested as an add-on to ondansetron in control of PONV and vertigo in middle ear surgery cases. MATERIALS AND METHODS: We conducted a prospective, randomized, double-blind, placebo controlled study, enrolling one hundred patients undergoing middle ear surgery under local anesthesia into two groups consisting of fifty (n = 50) patients each. Group A patients were given betahistine 16 mg plus ondansetron 8 mg and placebo plus ondansetron 8 mg were given to group B or placebo group, orally 3 hours before starting operation. The incidence of nausea, vomiting, and dizziness was noted during the intraoperative and postoperative 24 hours period. Chi-square test, unpaired 't' test, and Fisher's exact tests were performed for statistical analysis using SPSS version 16 and Open Epi version 2.3.1 softwares. RESULTS: Complete response was obtained in 90% patients in the betahistine group as compared to 66% in the placebo group. Vomiting in the intraoperative and postoperative period was noted in 4% and 8% cases, respectively, in the betahistine group as compared to 18% and 26%, respectively, in the placebo group. Overall, vertigo was 10% versus 32% in betahistine group and placebo group, respectively. CONCLUSION: Betahistine as an add-on to ondansetron can significantly attenuate PONV and perioperative vertigo, following middle ear surgeries.

Bilateral superficial cervical plexus block with or without low-dose intravenous ketamine analgesia: effective, simple, safe, and cheap alternative to conventional general anesthesia for selected neck surgeries.

BACKGROUND: General anesthesia is commonly used for surgery in the neck region. Superficial cervical plexus block is adequate to produce anesthesia in the anterior and anterolateral aspects of the neck. Our aim was to observe the effectiveness of bilateral cervical plexus block for surgery in this region of the neck. METHODS: A total of 136 neck surgery cases were enrolled in this prospective uncontrolled study. All patients were administered ropivacaine 0.5% as a bilateral cervical plexus block. The incision line was infiltrated with lignocaine 1% and adrenaline 1:100,000. For thyroglossal cyst and thyroglossal fistula, an additional 1.5 mL of LA solution was deposited over the hyoid bone on both sides of the midline. Any anesthetic inadequacy was corrected using ketamine 25 mg intravenously and repeated if necessary. RESULTS: Of 37 patients with thyroglossal cyst, the block was sufficient in 36 patients, and one patient required ketamine. Block was adequate in 23 of 24 patients with thyroglossal fistula, and one patient required ketamine. Among the branchial cyst and branchial fistula cases, six of 16 patients required ketamine supplementation. Of three thyroidectomy patients, one required ketamine supplementation, and one was converted to conventional general anesthesia. For lymph node excision and lymph node biopsy patients, LA block was sufficient in all 31 cases. In the last group, one of 25 patients required ketamine supplementation. CONCLUSION: The overall success of bilateral cervical plexus block as a sole method of anesthesia in these selected neck surgeries was 91.9% and with low-dose ketamine supplementation it approached more than 99%. However, cervical plexus block was not a good method of anesthesia for thyroid surgery in this study. For the remainder of cases, bilateral cervical plexus block alone or in conjunction with ketamine appeared to be a cheap, safe, and effective alternative to conventional general anesthesia.