Dexamethasone in anesthesia practice: A narrative review.

Dexamethasone is routinely used in anesthesia practice and has been regarded as one of the ideal perioperative agents. It is a synthetic glucocorticoid with potent antiinflammatory action. It reduces postoperative nausea and vomiting, pain, postoperative opioid requirements after general anaesthesia as well as spinal anaesthesia. It has been used via intravenous, epidural and perineural routes. It has been used successfully in fascial blocks. It significantly decreases fatigue, shivering and postoperative sore throat and improves quality of recovery.

Comparison of conventional with Parker flex-tip tracheal tube for intubation through air-Q intubating laryngeal airway.

BACKGROUND AND AIMS: The problem of difficult and failed intubation led to increased development of equipment for airway management. A number of supraglottic airways have now been developed to facilitate the passage of tracheal tubes. Conventional PVC tracheal tubes are recommended for intubation through the air-Q ILA. No study has compared different PVC tubes for blind intubation through air-Q ILA. Thus, we undertook this prospective, randomised, single blind study to compare two PVC tracheal tubes with different designs viz. conventional PVC tracheal tube (TT) and Parker flex-tip TT with regards to success rate, ease of intubation and total time required for successful intubation through air-Q ILA. MATERIAL AND METHODS: One hundred patients of either sex, aged 18-60 years, belonging to American Society of Anesthesiologists (ASA) physical status class I and II scheduled for elective surgery under general anesthesia requiring endotracheal intubation were included in the study. Blind intubation using conventional PVC TT and Parker flex-tip tube was done in group A (n = 50) and group B (n = 50), respectively. RESULTS: The first attempt success rate in Parker flex-tip TT was significantly more as compared to conventional PVC TT (P = 0.002). Success rate of intubation was significantly more in Parker flex-tip TT as compared to conventional PVC TT (P = 0.004). The intubation was significantly easy in Parker flex-tip tube as compared to conventional PVC TT (P = 0.002). Total time of intubation was less in Parker flex-tip tube as compared to PVC TT (P = 0.043). CONCLUSION: Unique design of the Parker Flex-tip TT resulted in increase in success rate, first attempt success rate and ease of intubation in group B in present study.

Intrathecal clonidine as an adjuvant to hyperbaric bupivacaine in patients undergoing inguinal herniorrhaphy: A randomized double-blinded study.

BACKGROUND: Clonidine is added to intrathecal local anesthetics to improve intraoperative analgesia and to increase the duration of sensory and motor block. Aim of this study was to evaluate and compare the effects of addition of two different doses of clonidine (15 and 30 mcg) to 11 mg hyperbaric bupivacaine in patients undergoing inguinal herniorrhaphy surgery under spinal anesthesia. MATERIALS AND METHODS: Seventy-five patients enrolled in the study were randomly divided into three groups of 25 each. Group I patients received 11 mg hyperbaric bupivacaine, whereas groups II and III received 15 mcg and 30 mcg clonidine, respectively, as an adjuvant to 11 mg hyperbaric bupivacaine. The volume of solution was kept constant to 2.4 ml by adding saline wherever needed. RESULTS: Highest level of sensory block, time to achieve this level, and highest Bromage scale recorded were comparable among the groups. The mean time to two-segment regression, regression of sensory block to L3 dermatome, and mean duration of motor block were the greatest in group III followed by group II and group I. There was significant fall in mean arterial pressure (MAP) in groups II and III as compared to group I (P = 0.04). Episodes of hypotension were more in group III than in group II. CONCLUSION: 30 mcg clonidine was associated with more incidence and duration of hypotension than 15 µg of clonidine. 15 mcg clonidine added to 11 mg hyperbaric bupivacaine provides better sensory and motor blockade for inguinal herniorrhaphy.

A prospective randomized study to evaluate the efficacy of pressure support ventilation with and without positive end expiratory pressure for preoxygenation in adult patients.

A primary concern for anesthesiologists is the maintenance of oxygenation during general anesthesia. Extending the safe apnea time, which is the time from the onset of apnea until the oxygen saturation concentration reaches 90% or less, increases the margin of safety with tracheal intubation. Preoxygenation before anesthetic induction has been a widely accepted manoeuver to increase oxygen reserves and hence delay the onset of arterial desaturation during apnea. This study aimed to evaluate the efficacy of pressure support ventilation with/without positive end-expiratory pressure (PEEP) for preoxygenation in adult patients. A total of 132 patients, aged 20 to 50 years, scheduled for elective surgery under general anesthesia, requiring endotracheal intubation, were included and randomly divided into three groups (n = 44 per group): spontaneous ventilation (SV), pressure support ventilation without PEEP (PS), and pressure support ventilation with PEEP (PEEP) groups. In the SV group, the patients breathed spontaneously without any support using a face mask; in the PS group, the patients breathed spontaneously with the inspiratory pressure support of 12 cm H2O without PEEP; and in the PEEP group, the patients were subjected to preoxygenation (similar to the PS group) with PEEP at 6 cm H2O. Preoxygenation was terminated when the fraction of expired oxygen reached 90% and the duration was recorded. Time from 90 seconds after administration of rocuronium bromide until oxygen saturation fell to 93% was recorded and taken as safe apnea time. The time taken for preoxygenation (the expired oxygen fraction reaches 90) was significantly shorter in patients of PEEP and PS groups when compared to the SV group. The safe apnea time was significantly longer in patients of PEEP and PS groups compared with the SV group. Application of inspiratory pressure support of 12 cm H2O and PEEP of 6 cm H2O during preoxygenation significantly reduces the preoxygenation time and prolongs the safe apnea time compared with conventional preoxygenation.

A randomised controlled trial to study Bispectral guided induction of general anaesthesia using propofol and etomidate infusion.

BACKGROUND AND AIMS: The present prospective, randomised study was done to evaluate induction characteristics with bispectral (BIS) index guided infusion of propofol and etomidate. MATERIALS AND METHODS: After institutional ethical committee approval, 70 patients, aged 18-60 years, American Society of Anaesthesiologists (ASA) I and II scheduled for elective surgery were included. Patients were randomly allocated into one of the two groups. In Group E, patients received etomidate infusion at a rate of 0.07 mg kg-1 min-1 and in Group P, received propofol infusion of 0.7 mg kg-1 min-1. Time from start of infusion to loss of palpebral reflex (TP), loss of verbal command (TV), BIS to reach 50 (TBIS50), mean induction dose and incremental dose of each drug required to keep BIS50., haemodynamic parameters and adverse effects like pain, myoclonus, apnoea and postoperative nausea and vomiting (PONV) were also noted. RESULTS: TP,TV, and TBIS 50 was faster in E as compared to P group and was statistically significant for all parameters. Mean induction dose of drug required till BIS 50 was 2.68 ± 0.56 mg kg-1 and 0.242 ± 0.11 mg kg-1 in group P and E, respectively. There was a significant difference between the groups with group E requiring incremental dose in a significant proportion of patients (P = 0.004). There was a significant decrease in MAP in P group as compared to E. In group P, more number of patients experienced pain and had apnoea episode as compared to group E. (P < 0.001). Myoclonus was observed in group E only (P = 0.016). CONCLUSION: BIS-guided titration of propofol and etomidate infusion for induction did not result in reduction of the dose, haemodynamic variations and other effects.

Comparative study of anatomical landmark-guided versus ultrasound-guided suprascapular nerve block in chronic shoulder pain.

BACKGROUND: Suprascapular nerve block (SSNB) is an effective method for the treatment of shoulder disorders. The present study was conducted to evaluate and compare the effectiveness of SSNB under ultrasonographic guidance with anatomical landmark-guided (LMG) technique in the treatment of chronic shoulder pain. MATERIALS AND METHODS: A total of fifty patients with shoulder pain were enrolled in the present prospective randomized study. Patients in Group I (n = 25) received SSNB using the anatomical LMG as technique described by Dangoisse, in whom a total of 6 ml of drug (5 ml of 0.25% bupivacaine and 40 mg methylprednisolone) was injected. Group II patients (n = 25) were given SSNB using the ultrasound guidance with the same amount of drug. Pain was measured using visual analog scale (VAS), range of motion and Shoulder Pain and Disability Index (SPADI) were recorded. Observations were recorded before the block, immediately after the block, and 1 and 4 weeks after the block. RESULTS: There was no statistically significant difference between the VAS score, range of motion and SPADI before the procedure (P > 0.05) in both the groups. Both the groups showed statistically similar improvement of VAS, range of motion and SPADI at 4-week (P > 0.05) follow-up. In Group I, VAS decreased from baseline value of 6.64 ± 1.50-2.04 ± 0.94 at 4 weeks (P < 0.001). In Group II, the VAS decreased from 6.92 ± 1.00 to 1.84 ± 1.03 at 4 weeks (P < 0.01). CONCLUSION: In our study, both the techniques have produced comparable relief of pain, improvement in shoulder movement, and decreased SPADI 4 weeks after the block.

A prospective study to evaluate and compare laryngeal mask airway ProSeal and i-gel airway in the prone position.

BACKGROUND: Prone position is commonly used to provide surgical access to a variety of surgeries. In view of the advantages of induction of anesthesia in the prone position, we conducted a randomized study to evaluate and compare ProSeal laryngeal mask airway (LMA) and i-gel in the prone position. MATERIALS AND METHODS: Totally, 40 patients of either sex as per American Society of Anesthesiologists physical status I or II, between 16 and 60 years of age, scheduled to undergo surgery in prone position were included in the study. After the patients positioned themselves prone on the operating table, anesthesia was induced by the standard technique. LMA ProSeal was used as an airway conduit in group 1 while i-gel was used in group 2. At the end of surgery, the airway device was removed in the same position. RESULTS: Insertion of airway device was successful in first attempt in 16, and 17 cases in ProSeal laryngeal mask airway (PLMA) and i-gel groups, respectively. A second attempt was required to secure the airway in 4 and 3 patients in PLMA and i-gel groups, respectively. The mean insertion time was 21.8 ± 2.70 s for group 1 and 13.1 ± 2.24 s for group 2, the difference being statistically significant (P < 0.05). The mean seal pressure in group 1 was 36 ± 6.22 cm H2 O and in group 2 was 25.4 ± 3.21 cm H2 O. The difference was statistically significant (P < 0.05). 13 patients in group 1 had fiberoptic bronchoscopy (FOB) grade 1 while it was 6 for group 2. The remaining patients in both groups had FOB grade 2. CONCLUSION: Insertion of supraglottic airways and conduct of anesthesia with them is feasible in the prone position. The PLMA has a better seal while insertion is easier with i-gel.

Comparison of ProSeal laryngeal mask airway size 2 and 2½ in anesthetized and paralyzed pediatric patients with same weight group: A prospective randomized clinical study.

CONTEXT: ProSeal laryngeal mask airway (PLMA) efficacy in pediatric anesthesia. AIMS: The aim of this study was to compare PLMA size 2 and 2½ in anesthetized paralyzed pediatric patients weighing 20-30 kg undergoing elective surgery. SETTINGS AND DESIGN: A prospective randomized study was conducted in a tertiary care teaching hospital. MATERIALS AND METHODS: A total of 60 American Society of Anesthesiologists I pediatric patients of either sex having body weight between 20 and 30 kg undergoing elective surgeries were randomly allocated to PLMA of either size 2 or 2½. Standardized anesthetic technique with propofol, sevoflurane, vecuronium bromide, nitrous oxide was used in all patients. Parameters such as number of attempts, time to achieve an effective airway, hemodynamic parameters, drain tube test, oropharyngeal leak pressure (OPL), gastric tube placement, and postoperative adverse events were noted. Statistical analysis by Kolmogorov-Smirnov analysis, Mann-Whitney U-test, Student's t-test, Wilk's lambda test and power analysis was done. RESULTS: There were no significant differences in demographic variables, ease of insertion and ventilation, number of insertion attempts, hemodynamics, and postoperative complications. OPLs were slightly higher in PLMA size 2½ (27.38 ± 6.36 vs. 22.62 ± 2.85 cm H2O, respectively; P = 0.001) than size 2. CONCLUSIONS: Both PLMA size 2 and 2½ provided adequate seal pressures that would allow positive pressure ventilation in healthy children. Thus PLMA of either size 2 or 2½ can be used as a reliable airway device in children weighing 20-30 kg.

Anesthetic management of a patient with Henoch-Schonlein purpura for drainage of cervical lymphadenitis: A case report.

Henoch-Schonlein purpura (HSP) is a multisystem disease and immunoglobulin A-mediated vasculitis with a self-limited course affecting the skin, joints, gastrointestinal tract, and kidneys. Severe renal and central nervous system disease may lead to life-threatening conditions, and immunosuppressive agents and plasmapheresis may be needed. We report successful management of a 6-year-old patient with HSP for drainage of cervical lymphadenitis.

Comparative evaluation of subclavian vein catheterisation using supraclavicular versus infraclavicular approach.

BACKGROUND AND AIMS: Infraclavicular (IC) approach of subclavian vein (SCV) catheterisation is widely used as compared to supraclavicular (SC) approach. The aim of the study was to compare the ease of catheterisation of SCV using SC versus IC approach and also record the incidence of complications related to either approach, if any. METHODS: In the study, 60 patients enrolled were randomly divided into two groups of 30 patients each. In Gp. SC right SCV catheterisation was performed using SC approach and in Gp. IC catheterisation was performed using IC approach. Access time, success rate of cannulation, number of attempts to cannulate vein, ease of guidewire and catheter insertion and length of catheter inserted and any associated complications were recorded. RESULTS: The mean access time in group SC for SCV catheterisation was 4.30 ± 1.02 min compared to 6.07 ± 2.14 min in group IC. The overall success rate in catheterisation of the right SCV using SC approach (29 out of 30) was better as compared with group IC (27 out of 30) using IC approach. First attempt success in the SC group was 75.6% as compared with 59.25% in the IC group. All successful subclavian vein  catheterisations in SC group and IC group were associated with smooth insertion of guidewire following subclavian venipuncture. CONCLUSION: The SC approach of SCV catheterisation is comparable to IC approach in terms of landmarks accessibility, success rate and rate of complications.

Chordal transfer in rheumatic mitral regurgitation: early experience.

Chordal transfer and chordal replacement techniques have been quite successful for repair of anterior mitral leaflet prolapse in degenerative disease, but largely unexplored in rheumatic patients. To extend the scope of valve repair, we assessed the chordal transfer technique for correction of anterior mitral leaflet prolapse in 57 patients with rheumatic mitral regurgitation, who were treated between October 2008 and March 2010. There were 36 women and 21 men with a mean age of 25 ± 7.4 years. Normal chordae and a strip of leaflet tissue were transferred from the posterior leaflet to the free edge of the anterior leaflet; the posterior leaflet was repaired in the same manner as after quadrangular resection. Additional procedures were commissurotomy in 19 patients, aortic valve replacement in 1, tricuspid repair in 5, and cryo maze operations in 21. There was no hospital mortality. One (1.7%) patient had acute renal failure but recovered fully. There was moderate regurgitation in one patient who had undergone simultaneous aortic valve replacement. At a mean follow-up of 6.2 ± 2 months, 56/57 (98.2%) patients were asymptomatic with no significant mitral regurgitation.