High soluble interleukin-2 receptor values in Indian paediatric & adult controls - Need for population-specific threshold in the diagnosis of haemophagocytic lymphohistiocytosis.

Background & objectives: Elevated soluble interleukin-2 receptor (sIL2R) is a diagnostic criterion for haemophagocytic lymphohistiocytosis (HLH). International guidelines propose a 2400 U/ml cut-off or individual laboratory-defined cut-off. However, sIL2R normal values are so far not known in Indians. So, this study was undertaken to measure sIL2R in healthy children and adults to establish age-related reference values. Methods: Healthy controls and cases (participants with persistent fever, organomegaly, cytopenias and biochemical markers of HLH) were prospectively enrolled. Serum sIL2R was measured by double-sandwich enzyme immunoassay in a standardization batch to determine the optimum cut-off value using receiver operator characteristic curve and was subsequently validated. Results: One hundred and forty six age- and sex-matched children (80 controls and 66 suspected HLH cases) and 55 adults (49 controls and 6 suspected HLH cases) were prospectively enrolled. The optimal sIL2R cut-off ≥23 ng/ml was defined as raised sIL2R in the standardization batch. No controls had sIL2R ≥23 ng/ml in the validation batch. In healthy controls, median sIL2R (interquartile range) decreased with increasing age from 9.0 ng/ml (6.6-13.4) below five years of age to 3.2 ng/ml (2.8-5.1) in adults. Proposed upper limit of normal value for sIL2R is 17.4 ng/ml in less than five year, 12.2 ng/ml in 5-9 yr, 6.7 ng/ml in 10-17 yr and 5.2 ng/ml in ≥18 yr. sIL2R accuracy to diagnose HLH marginally improved with age-appropriate cut-off. Interpretation & conclusions: Paediatric controls in India showed higher sIL2R levels than most studies conducted in other countries, except for some reports in Chinese and Russian populations. Age-appropriate reference values of sIL2R in a specific population may be considered to determine elevated sIL2R as a marker of HLH.

Comparison of bispectral index targeted end-tidal concentration of desflurane during three phases of orthotopic liver transplantation.

BACKGROUND AND AIMS: Reduced inhalational anaesthetic requirement in end-stage liver disease during living donor orthotopic liver transplantation (LD-OLT) is due to increased endogenous opioids. This study evaluated the changes in bi-spectral index (BIS) monitored end-tidal desflurane (ETDes) requirements during 'dissection', 'anhepatic', and 'neohepatic' phases of LD-OLT. METHODS: This prospective, cohort study included 40 adults undergoing LD-OLT under general anaesthesia (GA). All patients received BIS-guided desflurane GA. ETDes requirements in three phases of LD-OLT (primary objective); relationship between inhalational anaesthetic requirements and severity of liver disease; and effect of changes in mean arterial pressure (MAP) and body temperature on ETDes concentration for all three phases were also evaluated. RESULTS: ETDes during the 'dissection' phase (2.92 ± 0.65%) was > 'anhepatic' (2.68 ± 0.85%, P = 0.049) and 'neohepatic' phases (2.58 ± 0.71%, P = 0.005). Patients with model of end-stage liver disease (MELD) score < 20 returned significantly greater ETDes than those with MELD score ≥20 during the 'dissection' (MELD <20: 3.11 ± 0.49%; MELD ≥20: 2.58 ± 0.77%, P = 0.01) and 'anhepatic'(MELD <20: 2.96 ± 0.76%; MELD ≥20: 2.17 ± 0.79%, P = 0.003) phases. A positive correlation was observed between ETDes(r = 0.584, P = 0.001) and temperature in the 'dissection' phase only. CONCLUSION: In patients undergoing LD-OLT, BIS monitoring guidance of depth of desflurane GA suggests lower desflurane requirements during 'anhepatic' and the 'neohepatic' phase of surgery. Also, the desflurane requirement is greater in patients with lesser severity of liver disease.

Thoracic epidural analgesia in donor hepatectomy: An analysis.

The purpose of this study is to analyze whether supplementation of general anesthesia (GA) with thoracic epidural analgesia (TEA) for right lobe donor hepatectomy is a safe modality of pain relief in terms of changes in postoperative coagulation profile, incidence of epidural catheter-related complications, and timing of removal of epidural catheter. Retrospective analysis of the record of 104 patients who received TEA for right lobe donor hepatectomy was done. Platelet count, international normalized ratio, alanine aminotransferase, and aspartate aminotransferase were recorded postoperatively until the removal of the epidural catheter. The day of removal of the epidural catheter and visual analogue scale (VAS) scores were also recorded. Any complication encountered was documented. Intraoperatively, central venous pressure (CVP), hemodynamic variables, and volume of intravenous fluids infused were also noted. Statistical analysis was performed by using SPSS statistical package, version 17.0 (SPSS Inc. Chicago, IL). Continuous variables were presented as mean ± standard deviation. A total of 90% of patients had mean VAS scores between 1 and 4 in the postoperative period between days 1 and 5. None of the patients had a VAS score above 5. Although changes in coagulation status were encountered in all patients in the postoperative period, these changes were transient and did not persist beyond postoperative day (POD) 5. There was no delay in removal of the epidural catheter, and the majority of patients had the catheter removed by POD 4. There was no incidence of epidural hematoma. Aside from good intraoperative and postoperative analgesia, TEA in combination with balanced GA and fluid restriction enabled maintenance of low CVP and prevention of hepatic congestion. In conclusion, vigilant use of TEA appears to be safe during donor hepatectomy. Living liver donors should not be denied efficient analgesia for the fear of complications. Liver Transplantation 24 214-221 2018 AASLD.

Comparison of caudal epidural block and ultrasonography-guided transversus abdominis plane block for pain relief in children undergoing lower abdominal surgery.

STUDY OBJECTIVE: We conducted this study to compare the efficacy of caudal epidural block (CEB) vs ultrasonography-guided transversus abdominis plane (TAP) block for providing postoperative pain relief in children scheduled for lower abdominal surgery. Whereas the primary objective was to compare the duration of postoperative analgesia, the secondary objectives included comparative assessment (TAP vs CEB) of quality of pain relief in the first 24hours postoperatively and rescue analgesia requirements. DESIGN: Randomized-control, prospective, observer-blinded, 2-arm, single-center comparison. SETTING: Operating room, postoperative recovery area. PATIENTS: Eighty-children, aged 2-6years, of American Society of Anesthesiologists physical status I/II scheduled to undergo unilateral lower abdominal surgery under general anesthesia. INTERVENTIONS: The recruited children were randomly allocated to receive under general anesthesia either CEB (group C, 0.75 mL/kg of 0.25% bupivacaine) or ultrasonography-guided administration of TAP block (group T, 0.5 mL/kg of 0.25% bupivacaine). MEASUREMENTS: Intraoperative: heart rate and noninvasive blood pressure; postoperative: pain profile, including duration of postoperative analgesia, quality of pain relief, and rescue analgesia requirements. MAIN RESULTS: The median duration of postoperative analgesia was significantly greater in children who received CEB than those who were administered TAP block (group C: 362.5 minutes [172.5-693.75] vs group T: 210 minutes [108.75-362.5]; P<.05). No difference was found in the incidence of postoperative pain up to 6 hours from the point of initiation of assessment (group C: 47.2% vs group T: 55.9%; P>.05). The children who received CEB experienced greater incidence of pain in the 6- to 24-hour postoperative interval than those administered TAP block (group C: 75% vs group T: 44.1%; P<.05). Although there was no difference in the rescue analgesia requirements, the number of children not requiring any rescue analgesia in the first 24 hours postoperatively was significantly higher in the TAP group (group C: n=2 vs group T: n=8; P<.05). CONCLUSIONS: In children undergoing lower abdominal surgery, CEB provides a significantly prolonged duration of postoperative analgesia when compared with ultrasonography-guided TAP block.

A comparative study of Laryngeal Mask Airway size 1 vs. i-gel size 1 in infants undergoing daycare procedures.

BACKGROUND: The i-gel size 1 is a relatively new, single use, second generation supraglottic airway device. This prospective, randomized, observational study compares the suitability of the i-gel size 1 with the classical Laryngeal Mask Airway (cLaryngeal Mask Airway) size 1 in pediatric patients undergoing elective daycare procedures. METHODS: Forty ASA I and II children (2-5 kg body weight) were randomized to two groups of 20 each, to receive either the i-gel or the cLaryngeal Mask Airway as an airway device. The primary outcome variable was oropharyngeal seal pressure (OSP). We also assessed ease of insertion, number of insertion attempts, time taken for successful insertion and any intra-operative complications. RESULTS: Demographic data did not differ between the two groups. The OSP with the i-gel was 22.30 ± 4.72 cm H2O as compared to 18.05 ± 1.95 cm H2O with the cLaryngeal Mask Airway and the difference was statistically significant (P = 0.001). Displacement of the airway device following change of position was reported less often with the i-gel as compared to the cLaryngeal Mask Airway [n = 1 (5%) vs. n = 5 (35%), P = 0.04]. There were no major complications with either device and rest of all the variables were comparable with both the devices. CONCLUSIONS: The OSP of the i-gel size 1 was higher than that of the cLaryngeal Mask Airway. This was statistically significant, although may not be of clinical significance. The i-gel size 1 is less prone to displacement during position changes. However, being a preliminary study carried out on a small number of patients, further trials are warranted to come to any definite conclusion.

Significant air embolism: A possibility even with collapsible intravenous fluid containers when used with rapid infuser system.

Significant venous air embolism may develop acutely during the perioperative period due to a number of causes such as during head and neck surgery, spinal surgery, improper central venous and haemodialysis catheter handling, etc. The current trend of using self collapsible intravenous (IV) infusion bags instead of the conventional glass or plastic bottles has several advantages, one of thaem being protection against air embolism. We present a 56-year-old man undergoing kidney transplantation, who developed a near fatal venous air embolism during volume resuscitation with normal saline in collapsible IV bags used with rapid infuser system. To our knowledge, this problem with collapsible infusion bags has not been reported earlier.

Caudal clonidine in day-care paediatric surgery.

SUMMARY: We evaluated the analgesic efficacy, hemodynamic and respiratory safety of Clonidine when added to bupivacaine for caudal block. Forty children undergoing inguinal hernia repair were randomly given caudal injection with 0.75 ml.kg(-1) of bupivacaine (0.25%) and clonidine 2 mug.kg(-1) in Group C or 0.75 ml.kg(-1) of bupivacaine (0.25%) alone in Group B after induction of anaesthesia. Postoperatively duration of analgesia, OPS score (observational pain / discomfort scale), Sedation score, heart rate and blood pressure were recorded. Duration of analgesia was significantly longer (p<0.001) in Group C (10.25 hours) as compared to 4.55 hours in Group B. Bradycardia, hypotension and sedation were not observed in Group C. The addition of Clonidine in caudal blocks prolongs postoperative pain relief in children and is safe alternative to bupivacaine alone in paediatric daycare surgeries.