Preoperative fasting in children: An audit and its implications in a tertiary care hospital

Abstract Background

Anaesthetic Management of A Patient with Hypokalemic Periodic Paralysis- A Case Report

We report the anaesthetic management of a patient with hypokalemic periodic paralysis who underwent hepaticojejunostomy for stricture of the common bile duct. Patients with this disorder, who are apparently normal, can develop sudden paralysis as they are exposed to many of the predisposing factors, perioperatively. The complications due to this rare genetic disorder, the factors that can precipitate these problems and preventive measures are dis-cussed

Preoperative fasting in children: An audit and its implications in a tertiary care hospital

Background: Prolonged preoperative fasting in children is a common problem, especially in highvolume centers. All international professional society guidelines for preoperative fasting recommend 2 h for clear fluids, 4 h for breast milk and 6 h for solids, nonhuman and formula milk in children. These guidelines are rarely adhered to in practice. Aims: An audit was undertaken to determine the length of preoperative fasting time in children and its causes. Settings and Design: Cross-sectional study of 50 children below 15 years posted for elective surgeries. Materials and Methods: An initial audit was performed at our institution on preoperative fasting time in 50 children below 15 years of age for elective surgeries. The mean preoperative fasting times were found to be much longer than the recommended times. Ward nurses were then educated about internationally recommended preoperative fasting guidelines in children. Anesthesiologists started coordinating with surgeons and ward nurses to prescribe water for children waiting for more than 2 h based on changes in surgery schedule by instructing ward nurses through telephone on the day of surgery. A reaudit was done 6 months after the initial audit. Statistical Analysis Used: SPSS 16 software. Results: The initial audit revealed a mean preoperative fasting time of 11.25 h and 9.25 h for solids and water, respectively. Incorrect orders by ward nurses (74%) and change in the surgical schedule (32%) were important causes. After changing the preoperative system, mean preoperative fasting times in children decreased to 9 h and 4 h for solids and water, respectively in reaudit. Change in surgical schedule (30%) was the major cause for prolonged preoperative fasting in reaudit. Conclusions: Simple steps such as education of ward nurses and better coordination among the anesthesiologists, surgeons and nurses can greatly reduce unnecessary preoperative starvation in children

Awareness during anaesthesia for surgery requiring evoked potential monitoring: A pilot study

Background: Evoked potential monitoring such as somatosensory-evoked potential (SSEP) or motor-evoked potential (MEP) monitoring during surgical procedures in proximity to the spinal cord requires minimising the minimum alveolar concentrations (MACs) below the anaesthetic concentrations normally required (1 MAC) to prevent interference in amplitude and latency of evoked potentials. This could result in awareness. Our primary objective was to determine the incidence of awareness while administering low MAC inhalational anaesthetics for these unique procedures. The secondary objective was to assess the adequacy of our anaesthetic technique from neurophysiologist’s perspective. Methods: In this prospective observational pilot study, 61 American Society of Anesthesiologists 1 and 2 patients undergoing spinal surgery for whom intraoperative evoked potential monitoring was performed were included; during the maintenance phase, 0.7–0.8 MAC of isoflurane was targeted. We evaluated the intraoperative depth of anaesthesia using a bispectral (BIS) index monitor as well as the patients response to surgical stimulus (PRST) scoring system. Post-operatively, a modified Bruce questionnaire was used to verify awareness. The adequacy of evoked potential readings was also assessed. Results: Of the 61 patients, no patient had explicit awareness. Intraoperatively, 19 of 61 patients had a BIS value of above sixty at least once, during surgery. There was no correlation with PRST scoring and BIS during surgery. Fifty-four out of 61 patient’s evoked potential readings were deemed ‘good’ or ‘fair’ for the conduct of electrophysiological monitoring. Conclusions: This pilot study demonstrates that administering low MAC inhalational anaesthetics to facilitate evoked potential monitoring does not result in explicit awareness. However, larger studies are needed to verify this. The conduct of SSEP electrophysiological monitoring was satisfactory with the use of this anaesthetic technique. However, the conduct of MEP monitoring was satisfactory, only in patients with Nurick Grade 1 and 2. The MEP response was poor in patients with Nurick Grade 4 and 5

Epidural anesthesia and post-operative analgesia for bilateral inguinal mesh hernioplasty: Comparison of equipotent doses of ropivacaine and bupivacaine

Objectives: Ropivacaine is a long-acting amide local anesthetic, which is structurally very similar to bupivacaine but produces less motor block and less cardiac and central nervous system toxicity. It is also about 40% less potent than bupivacaine. Our double blind study was designed to compare the clinical efficacy of the equipotent doses of ropivacaine 0.75% and bupivacaine 0.5% for epidural anesthesia and ropivacaine 0.2% and bupivacaine 0.125% for post-operative analgesia in patients undergoing bilateral mesh hernioplasty. Methods: Sixty-one patients were randomized to receive 15 ml of 0.75% ropivacaine or 0.5% bupivacaine. Sensory and motor block characteristics were compared. Changes in heart rate, mean arterial blood pressure, and adverse effects were noted. For post-operative analgesia, 0.2% ropivacaine and 0.125% bupivacaine were given as continuous epidural infusion. Analgesia using VAS scores, motor block, volume of local anesthetic used and patient satisfaction was assessed. Results: There was no significant variation in the sensory block profile. A greater intensity of motor block was achieved with bupivacaine in the beginning but by 30 minutes the difference was not significant. Duration of motor block was similar in the two groups. Visual analog scale scores were similar in both groups during the post-operative period, with a similar motor block profile. No major side effects were noted in any group. Conclusion: The equipotent doses of ropivacaine and bupivacaine provided good quality epidural anesthesia and post-operative analgesia

Changes in central venous oxygen saturation, lactates, and ST segment changes in a V lead ECG with changes in hemoglobin in neurosurgical patients undergoing craniotomy and tumor excision: A prospective observational study

Background and Aims: The aim of the study was to observe the trends in central venous oxygen saturation (ScvO2), lactate, and ST segment changes with change in hemoglobin in patients undergoing acute blood loss during surgery and to assess their role as blood transfusion trigger. Material and Methods: Seventy-seven consecutive patients undergoing craniotomy at a tertiary care institution were recruited for this study after obtaining written, informed consent. After establishing standard monitoring, anesthesia was induced with standard anesthetic protocol. Hemodynamic parameters such as heart rate, blood pressure (mean, systolic, diastolic), pulse pressure variation (PPV), and physiological parameters such as lactate, ScvO2, ST segment changes were checked at baseline, before and after blood transfusion and at the end of the procedure. Statistical Analysis: Comparison of the mean and standard deviation for the hemodynamic parameters was performed between the transfused and nontransfused patient groups. Pearson correlation test was done to assess the correlation between the covariates. Receiver operating characteristic (ROC) curve was constructed for the ScvO2variable, which was used as a transfusion trigger and the cutoff value at 100% sensitivity and 75% specificity was constructed. Linear regression analysis was done between the change in hemoglobin and the change in ScvO2and change in hemoglobin and change in the ST segment. Results: There was a statistically significant positive correlation between the change in ScvO2and change in hemoglobin during acute blood loss with a regression coefficient of 0.8 and also between change in ST segment and hemoglobin with a regression coefficient of –0.132. No significant change was observed with lactate. The ROC showed a ScvO2cutoff of 64.5% with a 100% sensitivity and 75% specificity with area under curve of 0.896 for blood transfusion requirement. Conclusions: We conclude that ScvO2and ST change may be considered as physiological transfusion triggers in patients requiring blood transfusion in the intraoperative period

A comparative study of intrathecal and epidural buprenorphine using combined spinal-epidural technique for caesarean section

Neuraxial opioids provide excellent analgesia intraoperatively and postoperatively while allowing early ambulation of the patient by sparing sympathetic and motor nerves. A prospective, randomised double blind study was conducted involving 90 patients of ASA 1 physical status coming for elective cesarean section to evaluate the analgesic effect of neuraxial buprenorphine. They were allocated into three groups. Spinal local anaesthetic was used as the main stay of anaesthesia for surgery and spinal and epidural analgesia with opioids continued as the main stay for postoperative analgesia. All the groups were given 0.5% Bupivacaine intrathecally for the surgery. Besides this, group I was given 150 mcg Buprenorphine intrathecally and group II and III were given 150 mcg and 300 mcg Buprenorphine respectively, epidurally. In the present study, we observed that 150 mcg of Buprenorphine given intrathecally provided much longer duration of analgesia compared to 150 mcg of Buprenorphine given epidurally. Increasing the epidural dose of Buprenorphine from 150 mcg to 300 mcg proved to produce prolonged analgesia comparable to intrathecal Buprenorphine without compromising patient safety and neonatal outcome. The minor side effects were more with intrathecal Buprenorphine than epidural Buprenorphine. We concluded that 300 mcg of Buprenorphine epidurally is equianalgesic to 150 mcg Buprenorphine intrathecally