Postoperative pulmonary complications in patients with preoperative lung disease.

A prospective study was carried out on the incidence of pulmonary complications in 728 patients who underwent major surgical procedures at a reputed hospital in New Delhi. These patients were preoperatively assessed on the basis of history, clinical examination and bedside pulmonary function tests including PEFR, VC, FVC and FEV1. On the basis of these criteria, 212 patients had significant preoperative pulmonary disease, while 516 had normal lung functions. Postoperative pulmonary complications developed in 7.69 per cent of the patients. They were more frequent in smokers (P < 0.001) and in those with preoperative pulmonary dysfunction (P < 0.001). Their incidence was greater following thoraco-abdominal and musculoskeletal and miscellaneous operations compared to lower abdominal surgery (P < 0.001). The incidence was also higher following exposure to general anaesthesia compared to regional anaesthesia (P < 0.05). Pneumonia and atelectasis were the most common postoperative pulmonary complications. It was observed that the recovery of pulmonary functions was delayed in patients who developed postoperative pulmonary complications.

Over-the-needle versus microcatheter-through-needle technique for continuous spinal anesthesia: a preliminary study.

BACKGROUND AND OBJECTIVES: A new catheter-over-needle design (Spinocath, B. Braun) has been developed to minimize problems and complications of continuous spinal anesthesia with microcatheters, which include difficult catheter insertion, failure of insertion, breakage, inadequate anesthesia, postdural puncture headache, and, rarely, development of cauda equina syndrome. METHODS: A comparative evaluation of this new catheter (22-gauge Spinocath) to the microcatheter (28-gauge Portex) was performed to study the problems of insertion, complications, quality of anesthesia, and postoperative analgesia in a prospective, randomized manner. Patients were allocated to two groups of 10 each: catheter-over-the-needle group (group I) and microcatheter-through-the needle (group II). Postoperative protocol consisted of an infusion of 0.125% isobaric bupivacaine delivered with a syringe infusion pump for 24 hours. RESULTS: The two groups were comparable in relation to age, sex, type of surgery, median height of the block, and the time taken for catheter insertion and surgery. Spontaneous backflow of cerebrospinal fluid (CSF) through the catheter with the needle in position was possible only in the spinocath group (8/10 cases). Initial introduction of the catheter into the subarachnoid space (8 vs 3: chi-square = 5.05; P = .03) and threading of the catheter were easier (8 vs 3 cases: chi-square = 5.05; P = .03) in group I. Aspiration of CSF was easy in group I in all ( 10 vs 2: chi-square = 13.33; P = .004). Complications such as resistance to drug injection, kinking (P < .05), inadequate anesthesia, and supplementation with general anesthesia were seen only in group II. Postoperative pain relief was comparable in both groups (P > .05). Both groups were comparable hemodynamically in the intra- and postoperative periods. CONCLUSIONS: Insertion, maintenance, and clinical effects were better achieved with the catheter-over-the needle design compared to the microcatheter. These preliminary findings need to be confirmed by a larger study.

Biochemical hemodynamic and hematological changes during transcervical resection of the endometrium using 1.5% glycine as the irrigating solution.

OBJECTIVE: To study fluid absorption during transcervical resection of the endometrium (TCRE) and its effect on the biochemical, hemodynamic and hematological alterations so that life threatening complications of fluid overload may be prevented. METHOD: Intraoperative fluid (1.5% glycine) absorption in 46 women undergoing TCRE was studied and correlated using biochemical parameters (serum sodium, potassium, total proteins, creatinine and blood urea), hemodynamic parameters (pulse rate, blood pressure, oxygen saturation and end tidal CO2) and hematological parameters. Twenty five of these patients had received danazol (800 mg/day) for six weeks prior to TCRE. RESULT: The mean glycine deficit during TCRE was found to be 474.45 ml, with a mean total inflow of 3802.17 ml. Amongst all of the parameters, only serum sodium levels were found to be significantly inversely correlated with the glycine deficit. No case of hyponatremia occurred below a deficit of 1000 ml. Severe hyponatremia was reported in three cases (6.4%) and all three had a glycine deficit of more than 1000 ml. No case of pulmonary edema was noted. The mean glycine deficit was significantly lower (P=0.007) and the duration of procedure significantly shorter (P=0.0009) in the patients who had received danazol. None of the patients in the danazol group had fluid absorption of more than 1000 ml. CONCLUSION: Close monitoring of fluid inflow and outflow should be done during TCRE. Above a deficit of 1000 ml, serum sodium should be measured to detect significant hyponatremia. The use of danazol for endometrial preparation also reduces the mean amount of fluid absorbed.

Laryngeal changes following long-term stenting with polyvinyl chloride tubes.

BACKGROUND: To treat tracheal stenosis and permit wound healing to occur an inert stent is required which resists the contraction process and prevents re-stenosis. The newer stents of polyvinyl chloride are not readily available in India and endotracheal tubes are used in many centres. In our centre polyvinyl chloride tubes are used nasotracheally for prolonged periods. We prospectively studied the pattern of laryngeal changes that occur because of prolonged nasotracheal stenting with polyvinyl chloride tubes. METHODS: The incidence and pattern of laryngeal changes due to stents was prospectively studied at the time of removal of stents, using an operating microscope. Twenty-nine patients underwent tracheal reconstructive surgery for tracheal stenosis (post-intubation or post-tracheostomy) and tracheal injuries. RESULTS: Twelve different lesions were noted and their pattern was related to the period of stenting. Fibrosis, fibrous band formation and webs were noted after four weeks. A high incidence of laryngeal changes was seen in all age groups with an overall incidence of 79% (males 79%; females 88%; adults 82%, children 75%). The mean (SD) duration of stenting was 50 (33) days. Patients with laryngeal changes had a significantly (p < 0.05) longer duration of stenting [56 (34) days] compared to those without any lesion [29 (15) days]. CONCLUSIONS: After four weeks of stenting the severity and incidence of laryngeal changes increase. We recommend restriction of the use of polyvinyl chloride stents to less than four weeks to prevent permanent laryngeal damage.

Stress ulcer prophylaxis in patients on ventilator.

The objective of the study was to assess the efficacy of the H2-receptor antagonists and sucralfate for the prophylaxis of stress ulcer in patients on a ventilator in an intensive care unit in the general intensive care unit of our institute. A randomized, clinical controlled trial was conducted. Fifty-two critically ill patients, who required mechanical ventilation for more than 24 hours, were randomly divided into 3 groups. Group I received ranitidine 50 mg (intravenous) 8 hourly, group II received tablet sucralfate 1 g 8 hourly through a Ryle's tube, whereas group III was not given any drug. The incidence of upper gastrointestinal bleed, change in gastric pH and growth of gram-negative organisms in the gastric juice and bronchoalveolar lavage (BAL) culture were noted and analysed. The treatment groups were similar with respect to the baseline characteristics. The incidence of upper gastrointestinal bleeding was similar in the ranitidine (12.5%) and sucralfate groups (14.35%) but was high in the control group (57.14%). The mean gastric pH was significantly low in the control group (mean pH 2.07) compared to the ranitidine (mean pH 5.25) and sucralfate groups(mean pH 3.54)(p < 0.05). The incidence of positive culture for gram-negative organisms was significantly high in the ranitidine group (75%) in comparison with the sucralfate group (33.33%) (p < 0.002). However, the incidence of positive growth in the BAL culture was similar in all three groups. We conclude that both ranitidine and sucralfate are equally effective in decreasing the incidence of upper gastrointestinal haemorrhage and other stress- related lesions. Though ranitidine was more effective in increasing the gastric pH, the incidence of gastric colonization was higher in the ranitidine group compared to the sucralfate group.

A profile of nutritional practices and its cost in an intensive care in India.

In a retrospective study fifty patients admitted to a combined medical and surgical intensive care unit were surveyed to see the pattern of nutritional support. The routine practices of initial assessment and monitoring of the nutritional state, ordering and technique of feeding, routes of administration and complications were noted over a 3 week period. This gives an idea of the pattern of care and problems associated with nutritional support of the critically ill in this part of the world. The average cost of parenteral nutrition for three weeks was approximately Rs. 25,960 ($865 approx.) per patient.

Prophylactic dexamethasone for postoperative nausea and vomiting in pediatric strabismus surgery: a dose ranging and safety evaluation study.

In this double-blind, randomized, placebo-controlled study, we evaluated the efficacy and safety of different doses of prophylactic IV dexamethasone for postoperative nausea and vomiting (PONV) in 168 children (aged 2-15 yr) scheduled for strabismus surgery. Patients received IV dexamethasone 0.25 mg/kg (D 0.25), 0.5 mg/kg (D 0.5), 1.0 mg/kg (D 1), or saline (S) immediately after induction of general anesthesia. Patients were discharged 24 h after surgery. Nausea and vomiting were assessed at 0-2, 2-6, and 6-24 h after surgery. Blood glucose was measured preoperatively and at 4 h after study drug administration. Wound healing and infection were assessed after 1 wk. More patients in group S had vomiting at 0-2, 2-6, and 6-24 h (P = 0.001, P = 0.003, and P = 0.04, respectively) and required larger doses of rescue antiemetics compared with the dexamethasone groups. Fewer patients in the dexamethasone groups (6, 3, and 6 in D 0.25, D 0.5, and D 1, respectively) had severe PONV compared with group S (P = 0.001). No significant increase in postoperative blood glucose levels was observed and wound healing was satisfactory in all four groups. The results suggest that dexamethasone 0.25 mg/kg is more effective than saline and equally effective compared with larger doses for preventing PONV for pediatric strabismus surgery.

Phenytoin reduces suxamethonium-induced myalgia.

A prospective, randomised trial was undertaken in 60 healthy adults to determine the efficacy of intravenously administered phenytoin in doses of 5 mg.kg-1 for the prevention of suxamethonium-induced fasciculations, a rise in serum K+ and myalgia. This was compared with tubocurarine pretreatment and no pretreatment (control group). Phenytoin pretreatment significantly reduced myalgia from 45% (nine patients) in the control group to 10% (two patients) (p less than 0.05). It also decreased the duration and mean intensity of fasciculations. Incidentally, phenytoin was also found to decrease significantly mean serum Na+ levels (p less than 0.001) both at 5 and 20 min after administration. Tubocurarine pretreatment (3 mg) resulted in a significant decrease in fasciculations, but myalgia, which occurred in five patients, remained the same. No significant correlation was found between muscle fasciculations, postoperative myalgia and K+ changes, but patients with myalgia had a significant decrease in mean serum Na+ levels at 5 and 20 min after suxamethonium (p less than 0.01).

Remifentanil and propofol sedation for retrobulbar nerve block.

We studied remifentanil and propofol for analgesia and sedation during the placement of an ophthalmic block. Eighty ASA I or II patients undergoing elective cataract surgery under a retrobulbar block in a rural camp setting were included in the study. Patients were randomly divided into four groups and received different drug combinations as follows: Group I--remifentanil 1 microg/kg, Group II--remifentanil 0.5 microg/kg and propofol 0.5 mg/kg, Group III--remifentanil 1 microg/kg with propofol 0.5 mg/kg and Group IV--saline 0.1 ml/kg. Patients were observed for degree of movement, sedation, pain, recall and respiratory depression. No patient in the study groups reported pain or displayed movement whereas most of the patients in the control group had significant pain during the placement of the block. Also, seven (35%) patients in the control group showed significant movement which may have led to failure of block in two patients and retrobulbar haemorrhage in one patient. Incidence of significant respiratory depression was maximum in Group III patients (60%), followed by Group I (20%) and least in Group II (5%). All patients in the study groups remained cooperative and obeyed commands except four patients in group III (OAA/S-4). Postoperatively, other than the control group, recall was maximum in Group I (55%) and least in Group II (5%). Hence, a combination of remifentanil 0.5 microg/kg with propofol 0.5 mg/kg as a bolus was considered to provide excellent relief of pain and anxiety with least adverse effects for the placement of ophthalmic blocks.

Anaesthesia in arthrogryposis multiplex congenita: case report.

The anaesthetic management of an 11-year-old male with arthrogryposis multiplex congenita (AMC) with myopathic features is described. The child presented with an obstructing renal calculus and a pyelolithotomy via an anterior transverse subcostal extraperitoneal incision was performed. In view of the associated hypoplastic musculature, severe scoliosis and expected increased sensitivity to various sedatives and inhalational anaesthetic agents, low-dose ketamine (10-15 micrograms X kg-1 X min-1) was administered by continuous infusion, with a satisfactory result.

Intrathecal midazolam added to bupivacaine improves the duration and quality of spinal anaesthesia.

BACKGROUND: The antinociceptive action of intrathecal midazolam is well documented. In this prospective study, we investigated the addition of midazolam to intrathecal bupivacaine on the duration and quality of spinal blockade. METHODS: Forty ASA I or II adult patients undergoing lower abdominal surgery were selected for the study. The patients were randomly allocated to receive 3 ml of 0.5% hyperbaric bupivacaine intrathecally either alone or with 1 mg of midazolam using a combined spinal epidural technique. The duration and quality of sensory and motor block, perioperative analgesia, haemodynamic changes, and sedation levels were assessed. RESULTS: The duration of sensory block (i.e. time to regression to the S2 segment) was significantly longer in the midazolam group than the control group (218 min vs. 165 min; P < 0.001). The duration of motor block was also prolonged in the midazolam group as compared with the control group (P < 0.01). In 90% of the patients in the midazolam group, the quality of block was adequate during the intra-operative period as compared with only 65% of the patients in the control group (P < 0.05). The duration of effective analgesia was longer in the midazolam group than in the control group (199 vs. 103 min; P < 0.001). Blood pressure, heart rate, oxygen saturation and sedation scores were comparable in both groups. No neurological deficit or other significant adverse effects were recorded. CONCLUSION: The addition of intrathecal midazolam to bupivacaine significantly improves the duration and quality of spinal anaesthesia and provides prolonged perioperative analgesia without significant side-effects.