Confirmation of placement of endotracheal tube - A comparative observational pilot study of three ultrasound methods.

BACKGROUND AND AIMS: Confirmation of endotracheal tube (ETT) position is necessary to ensure proper ventilation. The present study was conducted with the aim to compare the efficacy of three ultrasonographic (USG) techniques in terms of time taken for confirmation of ETT position. The time taken by each USG technique was also compared with that for auscultation and capnography. The ability of the three USG techniques to identify tracheal placement of ETT was evaluated in all patients. MATERIAL AND METHODS: Ninety adult American Society of Anesthesiologists (ASA) I/II patients requiring general anaesthesia with tracheal intubation were randomised into three groups (n = 30 each) depending upon the initial USG transducer position used to confirm tracheal placement of ETT: group T (tracheal), group P (pleural) and group D (diaphragm). The time taken for confirmation of tracheal placement of ETT by USG, auscultation and capnography was recorded for each of the groups. Subsequently, USG confirmation of ETT placement was performed with the other two USG techniques in all patients. RESULTS: The time taken for USG in group T was significantly less (3.8 ± 0.9 s) compared to group P (12.1 ± 1.6 s) and group D (13.8 ± 1.7 s); P < 0.001. USG was significantly faster than both auscultation and capnography in group T (P < 0.001), whereas in group P and group D, USG took longer time compared to auscultation (P = 0.014 and P < 0.001, respectively) but lesser time than capnography (P < 0.001 in both groups). CONCLUSION: USG is a rapid technique for identification of ETT placement. All the three USG techniques are reliable in identifying the tracheal placement of ETT.

Low tidal volume ventilation strategy and organ functions in patients with pre-existing systemic inflammatory response.

BACKGROUND AND AIMS: Ventilation can induce increase in inflammatory mediators that may contribute to systemic organ dysfunction. Ventilation-induced organ dysfunction is likely to be accentuated if there is a pre-existing systemic inflammatory response. MATERIAL AND METHODS: Adult patients suffering from intestinal perforation peritonitis-induced systemic inflammatory response syndrome and scheduled for emergency laparotomy were randomized to receive intraoperative ventilation with 10 ml.kg-1 tidal volume (Group H) versus lower tidal volume of 6 ml.kg-1 along with positive end-expiratory pressure (PEEP) of 10 cmH2O (Group L), (n = 45 each). The primary outcome was postoperative organ dysfunction evaluated using the aggregate Sepsis-related Organ Failure Assessment (SOFA) score. The secondary outcomes were, inflammatory mediators viz. interleukin-6, tumor necrosis factor-α, procalcitonin, and C-reactive protein, assessed prior to (basal) and 1 h after initiation of mechanical ventilation, and 18 h postoperatively. RESULTS: The aggregate SOFA score (3[1-3] vs. 1[1-3]); and that on the first postoperative day (2[1-3] vs. 1[0-3]) were higher for group L as compared to group H (P < 0.05). All inflammatory mediators were statistically similar between both groups at all time intervals (P > 0.05). CONCLUSIONS: Mechanical ventilation with low tidal volume of 6 ml/kg-1 along with PEEP of 10 cmH2O is associated with significantly worse postoperative organ functions as compared to high tidal volume of 10 ml.kg-1 in patients of perforation peritonitis-induced systemic inflammation undergoing emergency laparotomy.

Postintubation Sequels: Influence of Fluticasone and Technique of Intra-Operative Muscle Relaxation.

BACKGROUND: Postintubation sequels (PIS) are a cause of serious concern in the postoperative period. AIM: The aim of this study is to find the influence of preoperative inhaled steroid and technique of muscle relaxation on PIS. SETTINGS AND DESIGN: This prospective, exploratory pilot study was conducted on 120 adult American Society of Anesthesiologist physical status Class I and II patients undergoing general anesthesia (GA) with muscle relaxation and cuffed endotracheal tube (ETT) insertion. PATIENTS AND METHODS: Patients were randomized into four groups as follows: intermittent muscle relaxation with preanesthetic inhalation of either distilled water puffs (Group ID) or fluticasone puffs (Group IF); continuous infusion of muscle relaxant with preanesthetic inhalation of either distilled water puffs (Group CD) or fluticasone puffs (Group CF). After induction of GA, ETT was inserted. The intra-cuff pressure was maintained constant. The trachea was extubated in the light plane in intermittent groups and in the deep plane in continuous groups. STATISTICAL ANALYSIS: Qualitative parameters were compared using the Chi-square test and quantitative parameters using repeated measure ANOVA followed by Tukey's test. RESULTS: Group CF had significantly less incidence of sore throat and hoarseness compared to groups ID and IF. The severity of sore throat was more in groups ID and IF than in groups CF and CD (P < 0.002). The severity of hoarseness was least in group CF (23.3%) and highest in group IF (90%). None of the patients had a cough in group CF. The incidence and severity of dysphagia were significantly less in group CF as compared to other groups (P < 0.005 and P < 0.008, respectively). CONCLUSION: Continuous infusion of muscle relaxant with extubation in deep plane of anesthesia with preanesthetic inhalation of fluticasone puffs results in lesser incidence and severity of PIS.

Intrathecal ropivacaine with or without tramadol for lower limb orthopedic surgeries.

BACKGROUND AND AIM: Preservative free tramadol has been used as an adjuvant to intrathecal bupivacaine. However, the effect of the addition of tramadol on intrathecal isobaric ropivacaine has never been studied. MATERIAL AND METHODS: This prospective, randomized, double-blind study was conducted in 50 adult male American Society of Anesthesiologists grade I or II patients, aged 18-60 years, being operated for unilateral femur fractures. An epidural catheter was inserted in L2-L3 interspace and subarachnoid block was given in L3-L4 space. The patients were randomized to receive 0.5 mL normal saline (group R) or 0.5 mL (25 mg) preservative free tramadol (group RT) with 2.5 mL of 0.75% intrathecal ropivacaine. Hemodynamic parameters, sensory level, motor block, sedation and side-effects were recorded. Statistical analysis was done using Student's t-test, Chi-square test, Fischer's exact test and repeated measures ANOVA. RESULTS: The time of sensory block onset was 9.2 ± 4.9 min and 8.6 ± 5.3 min (P = 0.714) in group R and group RT, respectively. The motor block onset was also comparable in both the groups (P = 0.112). The duration of sensory block was 147.2 ± 37.4 min in group R and 160.4 ± 40.9 min in group RT (P = 0.252). The median maximum block height achieved in both the groups was T6 and the time to achieve the maximum block was also comparable statistically (P = 0.301). CONCLUSION: The addition of intrathecal tramadol 25 mg to the isobaric ropivacaine does not alter the block characteristics produced by intrathecal ropivacaine alone.

Efficacy of dexmedetomidine as an adjuvant in paravertebral block in breast cancer surgery.

PURPOSE: This study evaluated the analgesic efficacy of dexmedetomidine in combination with bupivacaine for single-shot paravertebral block (PVB) in patients undergoing major breast cancer surgery. METHODS: This prospective, randomized double blind study was conducted in 45 ASA I/II/III females, aged ≥18 years, undergoing modified radical mastectomy or breast conservation surgery with axillary lymph node dissection. Patients in group PB (paravertebral-bupivacaine) received PVB with 0.5 % bupivacaine 0.3 ml/kg with 1 ml normal saline; group PBD (paravertebral-bupivacaine-dexmedetomidine) received PVB with 0.5 % bupivacaine 0.3 ml/kg and dexmedetomidine 1 µg/kg in a volume of 1 ml; and group C (control) patients were given a sham block (a subcutaneous injection with 2 ml normal saline) before receiving general anesthesia (GA). All patients received analgesia by fentanyl intraoperatively and morphine patient-controlled analgesia postoperatively. RESULTS: The control group patients required more intraoperative fentanyl than the other two groups. Patients receiving dexmedetomidine had lower morphine consumption (p < 0.001), pain scores and incidence of postoperative nausea/vomiting (p = 0.011); longer time to first analgesic request; earlier time to mobilize; and better satisfaction scores. Heart rate and blood pressure values during the intraoperative period were also lower at many time points in this group. However, the incidence of hypotension and bradycardia were statistically similar in all groups. CONCLUSIONS: PVB using dexmedetomidine 1 µg/kg added to 0.5 % bupivacaine in patients undergoing major breast cancer surgery under GA provides analgesia of longer duration with decreased postoperative opioid consumption and lower incidence of nausea/vomiting compared to PVB with bupivacaine alone or no PVB.

Presentation of research in anesthesia: Culmination into publication?

BACKGROUND: To assess the quality of research presentations made in conferences, its success or failure to be published in a peer-reviewed journal is a well-accepted marker. However, there is no data regarding the publication of research presentations made in Indian conferences of anesthesiology. OBJECTIVE: The primary objective was to determine publication rate of research presented at the largest and best attended national conference in anesthesiology, the Indian Society of Anaesthesiologists' Conference (ISACON), and also compare it with the rate from an international conference American Society of Anesthesiologists (ASA annual meeting) held in the same year. MATERIALS AND METHODS: All 363 abstracts presented as poster or podium presentations at the ISACON, and an equal number of randomly selected abstracts presented at ASA annual meeting were searched on Pubmed and Google Scholar for their full-text publications in peer-reviewed journals using a standardized search strategy. As secondary observations, abstracts were assessed for completeness by noting certain components central to research methodology. Also, changes between abstract of the presentation and published paper were noted with respect to certain components. RESULTS: The publication rate of presentations at ISACON and ASA meetings was 5% and 22%, respectively. The abstracts from ISACON lacked central components of research such as methods and statistical tests. The commonest change in the full-text publications as compared with the original abstract from both conferences was a change in authorship. CONCLUSION: Steps are required to augment full-text publication of Indian research, including a more rigorous peer review of abstracts submitted to ISACON to ensure their completeness.

ED50 of hyperbaric bupivacaine with fentanyl for cesarean delivery under combined spinal epidural in normotensive and preeclamptic patients.

BACKGROUND AND OBJECTIVES: The use of reduced intrathecal doses is advised for spinal anesthesia during cesarean delivery. However, there are inadequate data regarding the minimum effective dose of intrathecal bupivacaine for cesarean delivery. Preeclampsia is caused by an endothelial dysfunction leading to generalized vasoconstriction. Whether this can offset the pregnancy-induced decrease in intrathecal dose requirement caused by epidural venous dilation and consequent thecal compression is not known. There are no data to evaluate the minimum effective dose of intrathecal drug for cesarean delivery in preeclamptic patients. This study aimed to determine the minimum effective dose represented by the ED50 of intrathecal hyperbaric bupivacaine for normotensive and severely preeclamptic patients undergoing elective cesarean delivery. METHODS: Combined spinal epidural anesthesia was administered using a standardized technique on 18 consecutively preeclamptic and normotensive patients, each carrying an otherwise uncomplicated singleton pregnancy. The dose of intrathecal hyperbaric bupivacaine was decided by using the up-and-down method with an initial dose of 9 mg and dosing change of 1 mg. All patients received 20 µg of fentanyl intrathecally with bupivacaine. A successful block was defined as one that resulted in a sensory block to T4 level with modified Bromage score of 1 or 2 within 15 minutes of intrathecal injection. RESULTS: ED50 of intrathecal hyperbaric bupivacaine was identical in severely preeclamptic and normotensive parturients undergoing elective cesarean delivery (4.7 mg; 95% confidence interval, 4.5-4.9 mg). CONCLUSIONS: When a combined-spinal epidural is planned in normotensive or severely preeclamptic patients for an elective cesarean delivery, the ED50 of intrathecal hyperbaric bupivacaine along with 20 µg of fentanyl is 4.7 mg.

Role of thoracic epidural block in improving post-operative outcome for septic patients: a preliminary report.

BACKGROUND AND OBJECTIVES: Sepsis is considered a relative contraindication for epidural blockade. Recent evidence indicates that thoracic epidural blockade may be of benefit during sepsis by improving gut perfusion. This study was planned to evaluate whether combining thoracic epidural blockade with general anaesthesia could decrease the post-operative mortality and morbidity in patients with sepsis due to perforation peritonitis. METHODS: This randomised non-blinded study included consenting adult patients of the American Society of Anesthesiologists grade II-III, undergoing emergency laparotomy for small intestinal perforation peritonitis. Severity of illness was evaluated using Mannheim Peritonitis Index, Acute Physiology and Chronic Health Evaluation III score and clinical indicators of systemic inflammatory response syndrome. Patients were randomised into two groups depending on the anaesthetic technique [general anaesthesia combined with thoracic epidural block (group GT) and general anaesthesia (group GA), n = 33 each. The thoracic block was extended from T5 to T10 using 0.125% bupivacaine in aliquots of 2-3 ml, with 50 µg fentanyl. Post-operatively, patients were followed for occurrence of any major morbidity till discharge from hospital, and 30-day mortality. 'Major morbidity' included development of organ failure. Post-operative markers for gut motility and perfusion, that is, time to passage of flatus, stools, resumption of oral feeds and occurrence of anastomotic leak were also observed. Sample size was calculated at power of 80% and α error of 0.05, aiming to detect a decrease of 50% in the incidence of post-operative major morbidity or mortality. RESULTS: Patients in the two groups were similar with respect to demographic profile and severity of sepsis. The number of patients with major morbidity or 30-day mortality were statistically similar between the two groups (group GT, 0/33; group GA 4/33; P = 0.114). A significantly shorter time to pass stools and resume oral feeds in group GT (4 ± 2 vs. 3 ± 1 days) (P = 0.006 and 0.012, respectively) and lesser incidence of anastomotic leak (0/33 vs. 4/33; P = 0.114) showed earlier recovery of gut motility and perfusion in that group. CONCLUSION: Use of intra-operative segmental thoracic epidural blockade performed in addition to general anaesthesia suggested some benefit in improving post-operative mortality or major morbidity, but the trend was not significant, perhaps due to the small sample size. There was, however, a significantly earlier return of bowel motility and earlier discharge from hospital.

Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot study.

BACKGROUND: Thoracic epidural analgesia (TEA), a commonly used analgesic technique in patients with multiple fractured ribs, is technically demanding and associated with certain side effects or complications. Thoracic paravertebral block (TPVB) is a simple and effective method of providing continuous pain relief in these patients. However, it has never been compared with TEA in terms of efficacy and outcome in patients with fractured ribs. METHODS: Thirty adult patients of either sex, having three or more unilateral fractured ribs, were randomized to receive continuous bupivacaine infusion through either thoracic epidural or thoracic paravertebral catheter. Visual Analog Scale scores at rest and on coughing, respiratory rate, peak expiratory flow rate, and PaO2/FIO2 ratio were measured before and after administration of block at regular intervals. Morphine requirement for rescue analgesia, duration of bupivacaine infusion, length of intensive care unit and hospital stay, development of pulmonary complications, and complications of the two techniques were also recorded. RESULTS: Both TEA and TPVB provided good pain relief and improved respiratory function, as evident by improvement in Visual Analog Scale scores at rest and on coughing, respiratory rate, and peak expiratory flow rate. However, no significant intergroup differences were found. Duration of bupivacaine infusion, morphine requirement, length of intensive care unit and hospital stay, and incidence of pulmonary complications were also similar in the two groups. Incidence of hypotension was more in TEA group. CONCLUSIONS: Continuous bupivacaine infusion through TPVB is as effective as through TEA for pain management in patients with unilateral fractured ribs and the outcome after two techniques is comparable.

Evaluation of PR, RR, QT intervals and QT dispersion following stellate ganglion block in chronic shoulder-hand pain patients.

Right stellate ganglion block (SGB) can increase QT interval, rate-corrected QT interval (QTc), QT dispersion (QTD), rate-corrected QTD (QTcD), and RR interval while left SGB can decrease these intervals in healthy volunteers. No such studies have been conducted in patients with chronic pain, hence this study was designed to investigate the effects of left and right SGB on these variables in chronic shoulder-hand pain patients. In this study, 28 patients with chronic shoulder-hand pain of at least 6 months duration were given right or left SGB depending on the shoulder affected. A 12-lead electrocardiogram (ECG) was recorded before the block, 30 minutes and 60 minutes after the block. PR interval, RR interval, QT interval were recorded in all 12 leads while QTc, QTD, and QTcD were calculated. Right SGB was performed in 21 patients. A significant decrease (P < 0.05) in PR interval and a significant increase (P < 0.05) in RR interval, QT interval, and QTc interval were observed. QTD showed a significant increase (P < 0.05) only at 30 minutes after right SGB. Left SGB was performed in seven patients. A significant decrease (P < 0.05) in QT interval was observed throughout the study period, while QTc showed a significant decrease (P < 0.05) only at 60 minutes after the block. We conclude that right SGB induces significant increase of QT interval, RR interval, QTc interval, QTD, and a significant decrease of PR interval while left SGB produces a significant decrease in QT and QTc intervals in patients with chronic shoulder-hand pain.

An unusual complication of sinus arrest following right-sided stellate ganglion block: a case report.

We present a case of a 29-year-old female patient who had presented to us for the management of her chronic right shoulder-hand pain and developed a sinus arrest following a right-sided stellate ganglion block (RSGB). This patient on receiving a diagnostic RSGB via the anterior paratracheal (C6) approach developed sinus arrest followed by apnea and unconsciousness. On institution of resuscitative measures involving tracheal intubation, positive pressure ventilation, cardiac massage, and intravenous atropine, spontaneous cardiac activity recovered in about 3 minutes. Other signs and symptoms resolved fully in a total of 10 minutes. She had persistent postural hypotension lasting for about 24 hours requiring bed rest and was discharged about 36 hours after the procedure, without any adverse sequelae. As the sinus node is supplied by the right-sided sympathetic chain, its blockade probably resulted in unopposed parasympathetic activity leading to asystole. Available evidence of the role of right stellate ganglion in regulation of cardiac electrophysiology and functioning is also discussed.