Effect of Intramuscular Dexmedetomidine Administration Before Extubation on Post-Extubation Haemodynamics, Postoperative Sedation, and Analgesic Requirements: A Double Blind Placebo Controlled Study.

BACKGROUND: Dexmedetomidine, an α2-adrenoreceptor agonist has been successfully used for attenuating stress response to laryngoscopy. The present study was designed to evaluate the effects of intramuscular dexmedetomidine 30 minutes before extubation on hemodynamic response in patients undergoing laminectomy for prolapsed intervertebral disc (PIVD) under endotracheal intubation and general anesthesia. METHODS: Present double-blinded randomized placebo-controlled study, included 100 patients from either sex with American Society of Anesthesiologists grades I and II and age from 18 to 60 years undergoing laminectomy for PIVD under general anesthesia. Patients were randomly divided into two groups of 50 each based on computer generated random numbers. The study group received dexmedetomidine (2.0 µg/ kg, i.m.) in 2.5 mL saline, and the control group received normal saline (placebo, i.m.) 2.5 mL. Drugs had been administered 30 minutes before anticipated time of extubation intramuscularly at the deltoid region. Comparison of continuous variables between two groups was done by using student's unpaired t-test. Categorical data were analyzed by using chi-square test and Fischer Exact test as applicable. RESULTS: Heart rate was found to be significantly lower in the study group, 15 minutes before extubation (P = 0.003), during and after extubation (P ＜ 0.0001). The systolic and diastolic blood pressure was significantly lower in the study group during and after extubation (P ＜ 0.05). Cough was significantly lower in the study group during extubation. No significant difference was observed in other complications (respiratory stridor, incidence of laryngospasm or bronchospasm and reintubation) between the two groups. Pain score at 5 minutes, 2 hours, and 4 hours post-extubation was significantly lower in the study group (P ＜ 0.01). P-value ＜ 0.05 was considered statistically significant. CONCLUSIONS: Dexmedetomidine provides haemodynamic stability during extubation and post-extubation. It also provides post-operative calmness and reduces analgesic requirement and post-extubation complications.

A huffing manoeuvre, immediately before induction of anaesthesia, prevents fentanyl-induced coughing: a prospective, randomized, and controlled study.

BACKGROUND: Preinduction i.v. fentanyl bolus is associated with coughing in 28-65% of patients. Fentanyl-induced coughing (FIC) is not always benign and can be remarkably troublesome at the most critical moment of induction of anaesthesia when airway reflex is lost. We postulated that the huffing manoeuvre, a forced expiration against open glottis, just before i.v. fentanyl, may suppress this undesirable spasmodic cough. METHODS: Three hundred patients of ASA I and II, aged 18-60 yr, undergoing elective surgical procedures were randomly allocated into two groups consisting of 150 patients. Both groups received i.v. fentanyl (2.5 microg kg(-1)). Group 1 patients breathed normally whereas Group 2 patients were asked to perform huffing manoeuvre just before the fentanyl injection. The incidence of cough was recorded for 1 min before the induction of anaesthesia, and graded as mild (1-2 cough), moderate (3-5 cough), and severe (>5 cough). The incidence of FIC was analysed with Fisher's exact test and severity was analysed with the Mann-Whitney U-test. A P-value of <0.05 was considered significant. RESULTS: The incidence of cough was 32% in the control group and 4% in the huffing manoeuvre group (P<0.00). In the control group, 12% of FIC cases were moderate to severe in nature whereas no patient suffered severe coughing in the huffing manoeuvre group (P=0.049). CONCLUSIONS: A huffing manoeuvre performed just before i.v. fentanyl (2.5 microg kg(-1)) significantly reduces the incidence and severity of FIC in the majority of the patients.

Prophylactic gabapentin for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study.

BACKGROUND: Gabapentin is an antiepileptic drug. Its antiemetic effect is demonstrated in chemotherapy-induced acute and delayed onset of nausea and vomiting in breast cancer patients. AIM: To evaluate the antiemetic effect of gabapentin on incidence and severity of postoperative nausea and vomiting in laparoscopic cholecystectomy. SETTINGS AND DESIGN: Double-blind, randomized, placebo-controlled study. MATERIALS AND METHODS: Two hundred and fifty patients of ASA physical status I and II, scheduled for laparoscopic cholecystectomy were randomly assigned into two equal groups to receive 600 mg gabapentin or matching placebo two hours before surgery. Standard anaesthesia technique was used. Fentanyl was used as rescue postoperative analgesic. Ondansetron 4 mg was used intravenously as rescue medication for emesis. The total number of patients who had nausea or vomiting, and its severity and total fentanyl consumption in the first 24 hours were recorded. STATISTICAL ANALYSIS: "Z test" was used to test the significance of severity of post-operative nausea and vomiting between groups. Fentanyl consumed in each group (Mean+/-SD) within 24 hrs was compared using student t test. P value < 0.05 was considered significant. RESULTS: There were no demographic difference between the two groups. Incidence of post-operative nausea and vomiting within 24 hrs after laparoscopic cholecystectomy was significantly lower in gabapentin group (46/125) than in the placebo group (75/125) (37.8% vs 60%; P =0.04). There was a significantly decreased fentanyl consumption in gabapentin group (221.2+/-92.4 microg) as compared to placebo group (505.9+/-82.0 microg; P =0.01). CONCLUSION: Gabapentin effectively suppresses nausea and vomiting in laparoscopic cholecystectomy and post-operative rescue analgesic requirement.

Clinical evaluation of the "T-Dagger": a new bedside percutaneous dilational tracheostomy device.

A number of percutaneous dilational tracheostomy devices are now available for clinical use. Recently, a new percutaneous dilational tracheostomy device, the "T-Dagger" (Criticure Invasives, India), has been introduced for rapid bedside percutaneous tracheostomy. In a prospective preliminary study, we have performed percutaneous dilational tracheostomy (PDT) using the T-Dagger in 20 adult ventilated patients in order to evaluate the safety and efficacy of the new device. The T-Dagger facilitated bedside PDT in about 3 min with no untoward incidents. There was no significant bleeding, pneumothorax, pneumomediastinum, tracheal wall injuries or difficulty in ventilation in any of the patients. We conclude that the T-Dagger shows early promise in bedside percutaneous dilational tracheostomy. However, controlled studies are required in a larger patient population before it can be recommended for routine use.

Laryngeal mask airway vs endotracheal tube to facilitate bedside percutaneous tracheostomy in critically ill patients: a prospective comparative study.

BACKGROUND: Inadvertent puncture of endotracheal tube (ETT) cuff and accidental tracheal extubation are the potential life threatening complications during percutaneous dilatational tracheostomy (PDT). As an alternative to ETT, the laryngeal mask airway (LMA) has been used sporadically but no large study is available on its use. AIMS: To study the use of LMA during PDT on controlled ventilation in critically sick patients and compare its advantages and disadvantages in relation to ETT. SETTINGS AND DESIGN: This prospective, randomised, comparative study was conducted in intensive care unit of a super-speciality, tertiary care hospital. METHODS AND MATERIAL: The bedside PDT was performed in 60 critically ill patients using Ciaglia's kit. The patients received controlled ventilation of lungs either through ETT or LMA. The feasibility of the procedure and complications were compared in two groups. RESULTS: In LMA group, 33% of patients suffered with potentially catastrophic complications, e.g., loss of airway, inadequate ventilation of lungs leading to significant hypoxia, gastric distension and regurgitation. In ETT group there were 6.6% incidence of ETT impalement, 6.6% cuff puncture and 3.3% accidental tracheal extubation. Despite the technical difficulties (cuff puncture, etc.) the ETT technique was basically safe, whereas despite of the theoretical advantages the LMA technique rendered some patients at considerable risks of hypoxia and gastric regurgitation-aspiration. CONCLUSION: The LMA does not provide safe patent airway to facilitate bedside PDT in critically sick population on controlled ventilation. The ETT is safer for controlled ventilation and should be continued to secure the airway for this purpose until a better alternative is available.

Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein.

BACKGROUND: During subclavian vein catheterization, the most common misplacement of the catheter is cephalad, into the ipsilateral internal jugular vein (IJV). This can be detected by chest radiography. However, after any repositioning of the catheter, subsequent chest radiography is required. In an effort to simplify the detection of a misplaced subclavian vein catheter, the authors assessed a previously published detection method. METHODS: One hundred adult patients scheduled for subclavian vein cannulation were included in this study. After placement of subclavian vein catheter, chest radiography was performed. While the x-ray film was being processed, the authors performed an IJV occlusion test by applying external pressure on the IJV for approximately 10 s in the supraclavicular area and observed the change in central venous pressure and its waveform pattern. The observations thus obtained were compared with the position of catheter in chest radiographs, and the sensitivity and specificity of this method were evaluated using a 2 x 2 table. RESULTS: In 96 patients, subclavian vein cannulation was successfully performed. In four patients, cannulation was unsuccessful; therefore, these patients were excluded from the study. There were six misplacements of venous catheters as detected by radiography. In five (5.2%) patients, the catheter tip was located in the ipsilateral IJV, and in one (1.02%), the catheter tip was located in the contralateral subclavian vein. In the patients who had a misplaced catheter into the IJV, IJV occlusion test results were positive, with an increase of 3-5 mmHg in central venous pressure, whereas the test results were negative in patients who had normally placed catheters or misplacement of a catheter other than in the IJV. There were no false-positive or false-negative test results. CONCLUSION: The IJV occlusion test successfully detects the misplacement of subclavian vein catheter into the IJV. However, it does not detect any other misplacement. The test may allow avoidance of repeated exposure to x-rays after catheter insertion and repositioning.

Neuroendoscopic procedures: anesthetic considerations for a growing trend: a review.

The recent trend in neurosurgery is shifting toward further reduction in invasiveness to minimize trauma to the brain. Endoscopy holds the promise of shortened hospital stay with improved postoperative outcome. An important minimally invasive technique is neuroendoscopy. The ventricular system and subarachnoid space of the brain provide suitable conditions for the use of an endoscope. The currently available literature focuses only on recent advances in neuroendoscopy from the surgical perspective. To date, there is paucity of anesthetic literature emphasizing the implications for this growing trend. The surgical technique, instrumentation, anesthetic requirements, potential pitfalls and complications of this technique must be completely understood to ensure a successful outcome. The purpose of this review is to provide knowledge of indications, instrumentation, and anesthetic considerations in anticipation of complications steming from this procedure.

Combined use of isoflurane and sodium nitroprusside during active rewarming on cardiopulmonary bypass: a prospective, comparative study.

AIMS: To evaluate and compare the effect of isoflurane, sodium nitroprusside (SNP) and combined use of isoflurane and SNP on body rewarming and haemodynamic stability during active rewarming on cardiopulmonary bypass (CPB). SUBJECTS AND METHODS: In a prospective, randomised study 75 adult patients scheduled for coronary artery bypass grafting (CABG) under CPB were studied in three groups of 25 patients each. During active rewarming, patients of group I received SNP infusion in CPB, group-II received isoflurane through vaporiser in gas circuit of the CPB machine and group III received a combination of isoflurane inhalation (0.2-0.5%) + SNP in low doses (<1mg/kg/min). RESULTS: Mean requirements of SNP to achieve maximum pump flow during rewarming were 1.48 -/+ 0.65 mg/kg/min (range 0.3-3.5 mg/kg/min) in group I and 0.75 -/+ 0.25 mg/kg/min (range 0.2-0.85 mg/kg/min) in group III. Mean isoflurane concentration required to achieve maximum pump flow during rewarming was 0.95 -/+ 0.35% (range 0.2-1.5%) in group II and 0.35 -/+ 0.1 (range 0-0.4%) in group III. The requirements of SNP and isoflurane in group III were significantly less than group I and II (p<0.001). The haemodynamic stability was better in SNP + isoflurane group with significantly lesser requirement of inotropes. Four-scaled assessment for rewarming evaluation failed to show significant statistical difference amongst the groups. CONCLUSIONS: All three drug regimens were equally effective in terms of uniform rewarming of the body on CPB. However, combined use of SNP and isoflurane in low doses provides haemodynamic stability during CPB and is superior to either drug alone.

Ondansetron pretreatment to alleviate pain on propofol injection: a randomized, controlled, double-blinded study.

UNLABELLED: We used a randomized, controlled, double-blinded design to study the effect of ondansetron (OND) pretreatment on the pain produced by the IV injection of propofol. Eighty patients were randomly assigned to one of two groups: Group I received 2 mL of IV 0.9% saline pretreatment, and Group II received OND (4 mg in 2 mg/mL solution) pretreatment in the dorsum of the hand, followed by propofol 1 min later. Pain was reduced significantly in the OND group (P<0.05). Approximately one third of the patients in each group had myoclonic movements or skin rashes in the limb that received propofol. We conclude that the OND pretreatment may be used to reduce the incidence of pain on injection of propofol and to prevent postoperative nausea and vomiting. IMPLICATIONS: In a double-blinded, controlled study, IV ondansetron (4 mg) pretreatment was used to alleviate pain on injection of propofol. Ondansetron was successful in relieving pain without any adverse effect in a significant number of patients.

Internal jugular vein cannulation in neurosurgical patients: a new approach.

A new approach to internal jugular vein (IJV) cannulation with the head and neck placed in the neutral position is described. The junction of the medial two thirds and lateral one third between the angle of the mandible and symphysis menti is identified. A vertical line is drawn from this point to join another line drawn between the mastoid process and the medial end of the clavicle. The junction is the puncture point. In 120 patients studied, the failure rate was 1.66%, and there were no complications. We propose this technique as a safe and reliable alternative in neurosurgical patients.

Pneumoencephalus and convulsions after ventriculoscopy: a potentially catastrophic complication.

A nine-year-old boy with hydrocephalus underwent ventriculoscopy under general anesthesia. After introduction of ventriculoscope the patient had sudden bradycardia, hypotension, and shrinkage of ipsilateral cerebral hemisphere. The ventriculostomy was abandoned. At the end of anesthesia and endotracheal extubation, the patient developed generalized convulsions. Reexploration of wound did not reveal anything significant; however, postoperative CT scan of head showed massive pneumoencephalus. The patients received elective ventilation of lungs for 24 hours and made complete recovery. The authors describe the reasons for these complications and further management.

Efficacy of ondansetron in prophylaxis of postoperative nausea and vomiting in patients following infratentorial surgery: a placebo-controlled prospective double-blind study.

In a prospective double blind placebo-controlled study, 45 patients scheduled for infratentorial surgery were randomly allocated into two groups. Five patients were later excluded from the study because of various reasons. Out of 40 analyzable patients, 20 received IV Ondansetron (4 mg), whereas the other 20 received the matching placebo approximately 1 hour before the skin closure. After conclusion of surgery and tracheal extubation, all patients were monitored in the recovery room for post operative nausea and vomiting (PONV) for 48 hours. The incidence of PONV within the first 24 hours was found to be 50% and 10% in the placebo and ondansetron groups, respectively (p<0.05). After 24 hours, however, both groups were comparable in relation to the incidence of emesis. Rescue antiemetic (RAE) was required in nine (45%) patients in the placebo group and in two (10%) patients in the Ondansetron group (p<0.05). A significantly higher number of patients remained sedated postoperatively in the Ondansetron group than in the placebo group (p<0.05). One patient in the Ondansetron group had protracted diarrhea for 48 hours postoperatively. These results indicate that administration of IV Ondansetron (4 mg) 1 hour before skin closure effectively reduces PONV after infratentorial surgery, and does not have significant adverse effects.

Percutaneous dilational tracheostomy: the Ciaglia method versus the Portex [correction of Rapitrach] method.

UNLABELLED: In a prospective study, we performed percutaneous dilational tracheostomy (PDT) using either the Ciaglia method (gradual dilation) or the Portex [corrected] method (single dilation) in 80 patients. We encountered difficulty in dilating the tracheal stoma of three (7.5%) patients in the Ciaglia group because of tight pretracheal fascia. It was difficult to insert the tracheostomy tube in four (10%) patients in the Portex [corrected] group even after appropriate tracheal dilation. However, the tracheal cannulation was successfully completed in all patients in subsequent attempts. The mean time for completion of the procedures, from skin incision to insertion of the tracheostomy tube, was 14+/-5.5 min with the Ciaglia method and 6.5+/-3.5 min with the Portex [corrected] method. PDT with either method has not been associated with clinically significant hemorrhage, infection at the stoma site, or cosmetic deformity. In a follow-up period of 9 mo, none of our decannulated patients presented with clinical tracheal stenosis. Our results indicate that PDT with both methods is as safe and easy to organize and perform as a bedside procedure, obviating the need to transport critically ill patients from the critical care unit. IMPLICATIONS: The tracheas of 80 patients were cannulated through an artificial opening using either the Ciaglia (gradual dilation) or the Portex [corrected] (single dilation) method. Both techniques were successful with no significant complications. After 9 mo of closure of this opening, none of the survivors had significant scarring or narrowing of the trachea.