Accuracy in Blood Pressure Monitoring: The Effect of Noninvasive Blood Pressure Cuff Inflation on Intra-arterial Blood Pressure Values.

CONTEXT: Both invasive and noninvasive blood pressure (invasive arterial blood pressure [IABP] and noninvasive BP [NIBP]) monitors are used perioperatively; however, they often produce different values. The reason for this discrepancy is not clear, and it is possible that the act of cuff inflation itself might affect the IABP values, especially with the recurrent cycling of NIBP cuff. AIM: The aim of this study was to determine the effect of ipsilateral NIBP cuff inflation on the contralateral IABP values. SETTINGS AND DESIGNS: Prospective, observational study. MATERIALS AND METHODS: One hundred consecutive patients were studied. The NIBP device was set to cycle every 5 min for a total of 6 times. During each cuff inflation cycle, changes in IABP values from the arterial line in the contralateral arm were recorded. A total of 582 measurements were included for data analysis. STATISTICAL ANALYSIS: Chi-square, paired t-test, analysis of variance. RESULTS: Mean (± standard deviation) changes in systolic BP (SBP), diastolic BP, and mean BP with cuff inflation were 6.7 ± 5.9, 2.6 ± 4.0, and 4.0 ± 3.9 mmHg, respectively. We observed an increase of 0-10 mmHg in SBP in majority (73.4%) of cuff inflations. The changes in IABP did not differ between the patients with or without hypertension or with the baseline SBP. CONCLUSIONS: This study showed that there is a transient reactive rise in IABP values with NIBP cuff inflation. This is important information in the perioperative and intensive care settings, where both these measurement techniques are routinely used. The exact mechanism for this effect is not known but may be attributed to the pain and discomfort from cuff inflation.

Congenital lymphedema complicated by pain and psychological distress: case report.

Patients with congenital lymphedema who experience pain report more functional interference and psychiatric disturbances than those without pain. These patients also have body image disturbance. We hereby report a case illustrating how pain relief can help in rehabilitative aspect and improve the quality of life and also help to overcome psychiatric manifestation. Pain related to lymphedema is often a neglected aspect of this overlooked problem.

Comparison of general anaesthesia versus regional anaesthesia with sedation in selected maxillofacial surgery: a randomized controlled trial.

BACKGROUND: The airway is the foremost challenge in maxillofacial surgery. The major concerns are difficulty in managing the patient's airway and sharing it between the anaesthetist and surgeons. General anaesthesia, with endotracheal intubation, is the commonly used technique for maxillofacial procedures. We assessed the efficacy and safety of a regional block with sedation technique in certain maxillofacial operations, specifically temporomandibular joint (TMJ) ankylosis and mandibular fracture cases, and compared it with conventional general anaesthesia. We compared the time to discharge from the post anaesthesia care unit (PACU) and the occurrence of side effects, as well as surgeon and patient satisfaction with the anaesthetic technique, between the two groups. MATERIALS & METHODS: We enrolled 50 patients of ASA grade 1 or 2, aged 15-50 years, scheduled for maxillofacial surgery (mandibular fracture or TMJ ankylosis). The patients were divided into two groups of 25 each, to receive sedation with a regional block with the use of a peripheral nerve stimulator in group I and general anaesthesia in group II. We observed haemodynamic parameters, intraoperative and postoperative complications and the amount of surgical bleeding in the two groups. Total anaesthesia time, patient and surgeon satisfaction, time to rescue analgesia, the number of rescue doses required, and the time to discharge from the PACU were compared. RESULTS: The groups were comparable with respect to demographic profile, intraoperative haemodynamic parameters, surgical time, and amount of blood loss. Postoperative pain was assessed using the visual analogue score (VAS). Patients in group I had lower VAS scores after surgery and remained pain-free for longer than those in group II. The mean pain-free interval in group I was 159.12 ± 43.95 min and in group II was 60.36 ± 19.77 min (p < 0.005). Patients in group I required lower doses of rescue analgesia than those undergoing the surgery under general anaesthesia (p < 0.005). Patients receiving regional blocks also had fewer episodes of postoperative nausea and vomiting (p = 0.005). These results led to earlier discharge of patients in group I from the PACU. CONCLUSIONS: Regional block with sedation is a safe alternative technique for patients undergoing surgery for mandible fracture or TMJ ankylosis, with clear advantages over general anaesthesia.

Comparison between intranasal dexmedetomidine and intranasal ketamine as premedication for procedural sedation in children undergoing MRI: a double-blind, randomized, placebo-controlled trial.

INTRODUCTION: Providing anesthesia to children undergoing MRI is challenging. Adequate premedication, administered noninvasively, would make the process smoother. In this study, we compare the efficacy of intranasal dexmedetomidine (DXM) with the intranasal administration of ketamine for procedural sedation in children undergoing MRI. METHODS: We studied 150 children, between 1 and 10 years of age, divided randomly into three groups (DXM, K, and S). For blinding, every child received the intranasal drugs twice; syringe S1, 60 min before, and syringe S2, 30 min before intravenous (IV) cannulation. For children in group DXM, S1 contained DXM (1 µg/kg) and S2 was plain saline. Children in group K received saline in S1 and ketamine (5 mg/kg) in S2 whereas children in group S received saline in both S1 and S2. The child's response to drug administration, ease of IV cannulation, the satisfaction of the anesthesiologist and child's parents with the premedication, and the total propofol dose required for the satisfactory conduct of the procedure were compared. We also compared the time to awakening and discharge of the child as well as the occurrence of any side effects with these drugs. RESULTS: Both DXM and ketamine were equally effective as premedication in these patients. Most of the children accepted the intranasal drugs with minimal discomfort; 90.4 % of the anesthesiologists in the DXM group and 82.7 % in the ketamine group were satisfied with the conditions for IV cannulation whereas only 21.3 % were satisfied in the saline group. The total dose of propofol used was less in the study groups. Furthermore, children in group DXM and group K had earlier awakening and discharge than those in group S. CONCLUSION: DXM and ketamine were equally effective, by the intranasal route, as premedication in children undergoing MRI.

ß2 agonist for the treatment of acute lung injury: a systematic review and meta-analysis.

BACKGROUND: The use of ß2 agonist as an intervention for acute lung injury (ALI) and ARDS patients is controversial, so we performed a systematic review and meta-analysis of the published randomized controlled trials of using ß2 agonists to improve outcomes (mortality and ventilator free days) among patients with ALI/ARDS. METHODS: A comprehensive search of 7 major databases (Ovid MEDLINE In-Process and other non-indexed citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Cochrane Database of Systematic Reviews, Web of Science, and Scopus) for randomized controlled trials using ß2 agonists for ALI from their origin to March 2013 was conducted. The effect size was measured by relative risk for dichotomous outcomes, and mean difference for continuous outcomes, with 95% CI. The statistical heterogeneity between the studies was assessed with the Cochran Q test and I(2) statistic. The heterogeneity of > 50% was considered significant for the analysis. The Cochrane risk of bias tool was used to ascertain the quality of the included studies. RESULTS: Out of 219 studies screened, 3 randomized controlled trials reported mortality and ventilator-free days, in 646 ALI/ARDS subjects. Of the 646 subjects, 334 (51.7%) received ß2 agonist and 312 (48.3%) received placebo. There was no significant decrease in 28-day mortality or hospital mortality in the ß2-agonist group: relative risk 1.04, 95% CI 0.50-2.16, and relative risk 1.22, 95% CI 0.95-1.56, respectively. The ventilator-free days and organ-failure-free days were significantly lower for the ALI subjects who received ß2 agonists: mean difference -2.19 days (95% CI -3.68 to -1.99 d) and mean difference -2.04 days (95% CI -3.74 to -0.35 d), respectively. CONCLUSIONS: In subjects with ALI/ARDS, ß2 agonists were not only nonbeneficial in improving the survival, but were harmful and increased morbidity (reduced organ-failure-free days and ventilator-free days). The current evidence discourages the use of ß2 agonist in ALI/ARDS patients. (International Prospective Register of Systematic Reviews, http://www.crd.york.ac.uk/prospero, 2012:CRD42012002616.).

The effect of tranexamic acid on hemoglobin levels during total knee arthroplasty.

The aim of this study was to evaluate the efficacy of perioperative administration of 1,4-amino-carboxylic acid (tranexamic acid) in reducing the intraoperative and postoperative blood loss in patients undergoing total knee replacement (TKR). Tranexamic acid is an antifibrinolytic agent that is 7-10 times as potent as epsilon aminocaproic acid. We had investigated the effect of tranexamic acid on blood loss intraoperatively and postoperatively during and after TKR thereby significantly preventing a decrease in postop Hb in these patients. This study was a randomized, prospective, observational, double-blinded study on 99 patients, after obtaining ethical committee approval and valid informed consent from patients to be part of the study. In the study group, the drug was administered in 2 doses 1 hour preoperatively and 6 hours postoperatively. The use of tranexamic acid injection in TKR surgeries can be considered as an effective method to control and minimize the blood loss during total knee arthroplasty surgeries.

Kounis syndrome resulting from anaphylaxis to diclofenac.

"Kounis syndrome" refers to acute coronary syndromes of varying degree (myocardial ischaemia to infarction) induced by mast cell activation as a result of allergic and anaphylactic reactions. ST-segment elevated myocardial infarction is a rare complication that can occur even in patients with normal coronary arteries due to anaphylactic reactions. We present a case that developed acute myocardial infarction following a diclofenac sodium-induced anaphylaxis. The patient did not have any previous coronary artery disease, but there was a temporal relationship with development of the anaphylactic reaction due to diclofenac sodium and the cardiac event. The patient was managed conservatively and the recovery was uneventful.

Intrathecal bupivacaine in comparison with a combination of nalbuphine and bupivacaine for subarachnoid block: a randomized prospective double-blind clinical study.

We performed this randomized, prospective double-blind study to evaluate the effects of 2 different doses of intrathecal nalbuphine (a synthetic opioid agonist-antagonist) on the onset, duration of action, side effects, and complication produced by intrathecal hyperbaric 0.5% bupivacaine in lower abdominal, urologic and lower limb surgeries. Seventy-five patients of ASA grades 1 and 2 of either sex in the age group of 20-60 years were randomly allocated to 1 of 3 groups. Group A (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL sterile water intrathecally; group B (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL (200 µg) nalbuphine intrathecally; group C (n = 25) received 2.5 mL of 0.5% hyperbaric bupivacaine + 1 mL (400 µg) nalbuphine intrathecally. The onsets of sensory and motor blockade, highest level of sensory blockade, 2 segment regression time of sensory blockade, duration of motor blockade and analgesia, visual analog scale score, hemodynamic and respiratory changes, side effects were recorded, tabulated, and analyzed. Onsets of sensory and motor blockade and duration of motor blockade were not affected. Two segment regression time of sensory blockade and duration of analgesia were maximally prolonged in group C (P < 0.05). The visual analog scale scores were in the following order: group A > group B > group C at 90, 120, and 150 minutes after induction (P < 0.05). Hemodynamic and respiratory complications were absent except in 2 patients in groups A and C each, and 1 patient in group B developed bradycardia (P > 0.05). One patient in group A had nausea and vomiting, 2 patients in each group developed shivering (P > 0.05). No other side effect or complication was observed. Nalbuphine hydrochloride (400 µg) significantly prolongs the duration of sensory blockade and postoperative analgesia without any side effect or complication when introduced intrathecally along with hyperbaric bupivacaine.

Anaphylaxis related to fentanyl citrate.

Anaphylaxis is a fulminant, unexpected, immunoglobulin E-mediated allergic reaction that can be triggered by multiple agents. Common causative agents include neuromuscular blocking drugs, latex, antibiotics, colloids, hypnotics, and opioids. Fentanyl citrate, however, is an extremely unusual cause of anaphylaxis. Pulmonary edema, although uncommon in anaphylaxis, can be a prominent feature, as was in one of the patient. An adverse drug reaction is a noxious or unintended reaction to a drug that is administered in standard doses by the proper route for the purpose of prophylaxis, diagnosis, or treatment. Reactions are classified into two major subtypes: type A, which are dose dependent and predictable; and type B, which are not dose dependent and unpredictable. Unpredictable reactions include immune (allergic) or no immune drug hypersensitivity reactions and are related to genetic susceptibilities or undefined mechanisms (formally called idiosyncratic and intolerance reactions). A drug allergy is always associated with an immune mechanism for which evidence of drug-specific antibodies or activated T lymphocytes can be shown. In the last few years, many novel drugs have entered clinical practice (i.e., biologic agents) generating novel patterns of drug hypersensitivity reactions. As old drugs continue to be used, new clinical and biologic techniques enable improvement in the diagnosis of these reactions.

Anaesthetic significance and management of a child with neonatal purpura fulminans.

Protein C deficiency is a rare autosomal-dominant disorder of varying severity. Patients with homozygous and compound heterozygous protein C deficiency present with neonatal purpura fulminans (NPF). Other presentations usually include disseminated intravascular coagulation and venous thromboembolism. This disorder usually poses a unique anaesthetic challenge to the anaesthesiologist, requiring special precautions to prevent various intra- and post-operative complications. We hereby report the successful anaesthetic management of a 1-month-old infant who presented with NPF.

Ketotic hyperglycemia with movement disorder.

Chorea, hemichorea-hemiballismus and severe partial seizures may be the presenting features of nonketotic hyperglycemia in older adults with type 2 diabetes, but cases in young adults with type 1 diabetes are rare. We hereby report a very rare case of diabetic ketosis with movement disorder in a young patient.

Anaesthetic management of peripartum cardiomyopathy using "epidural volume extension" technique: a case series.

Peripartum cardiomyopathy is a rare cause of dilated cardiomyopathy in parturients, occurring in approximately one in 1000 deliveries, manifesting during the last few months or the first 5 months of the postpartum period. It can result in severe ventricular dysfunction during late puerperium. The major concern while managing these patients is to optimize fluid administration and avoid myocardial depression, while maintaining stable intraoperative hemodynamics. We present a case series of five parturients that were posted for elective cesarean section and managed successfully by the epidural volume extension technique.

Epidural volume extension: A novel technique and its efficacy in high risk cases.

We present a unique case series restricting ourselves only to the high-risk case of different specialities who underwent successful surgery in our Institute by using epidural volume extension's technique using 1 mL of 0.5% ropivacaine and 25 µg of fentanyl.

Allergy to lactated ringer solution-an unusual case presentation.

Allergic reactions may be noted by an anesthesiologist during various stages of anesthesia that include induction, maintenance, and post anesthesia care. The incidence of allergic reactions is most common in the perioperative period as a result of various drugs being used concomitantly. It is of paramount importance that an allergic reaction be rapidly diagnosed and adequately treated, because anaphylaxis and acute allergic reactions can occur within minutes in a sensitized individual and can be fatal. Here, we report a case of allergic reaction encountered during induction of anesthesia, after administration of intravenous infusion using lactated Ringer solution.

Takayasu's arteritis: Anesthetic significance and management of a patient for cesarean section using the epidural volume extension technique.

Takayasu's arteritis (TA) is a rare, chronic progressive pan-endarteritis involving the aorta and its main branches. Anesthesia for patients with TA is complicated by severe uncontrolled hypertension, end-organ dysfunction, stenosis of major blood vessels, and difficulties in monitoring arterial blood pressure. We present the successful anesthetic management of a 23-year-old woman having TA with bilateral subclavian and renal artery stenosis posted for emergency cesarean section by using the epidural volume extension technique, which offers the combined advantage of both spinal and epidural anesthesia and, at the same time, also avoids the need of sophisticated neurological monitors like EEG and transcranial Doppler.