Comparison of haemodynamic responses in normotensive and hypertensive patients among three intubation devices: macintosh laryngoscope, intubating laryngeal mask airway and lightwand

Background: The pressor response to endotracheal intubation is of special concern, especially in the presence of comorbidities like diabetes, hypertension, obesity and ischemic heart disease (IHD). It is commonly assumed that insertion of laryngeal mask airway (LMA) is associated with lesser hemodynamic fluctuations than conventional laryngoscopy. Also, the lightwand (LW) is believed to provoke a milder pressor response as it does not involve elevation of epiglottis. We decided to evaluate the pressor response to all three devices in normotensive and hypertensive patients.   Methods: We conducted a randomized prospective study consisting of 126 patients posted for surgical procedures under general anesthesia. 63 hypertensive and 63 normotensive patients were randomly assigned to each intubation device: the macintosh laryngoscope (LS), the lightwand (LW), and the intubating laryngeal mask airway (ILMA).The peri-intubation hemodynamic parameters were recorded. Statistical analysis was done with SPSS version 17.0 Inter- and intra-group differences among the hemodynamic variables recorded over time were analyzed by using one-way analysis of variance for repeated measures with bonferroni post-test analysis as appropriate. All quantitative data were expressed as mean±standard deviation (SD). A p-value less than 0.05 was considered statistically significant.Results: All 3 devices (LS, ILMA and LW) are comparable with respect to hemodynamic fluctuations in normotensive patients. However, in hypertensive patients conventional laryngoscopy was associated with greater hemodynamic fluctuations than ILMA or LW. However there was no significant difference in the hemodynamic fluctuations between ILMA and LW.Conclusions: The ILMA and LW may be preferable to LS in hypertensive patients where attenuation of hemodynamic stress response is desired

Effect of intravenous clonidine premedication in patients undergoing laparoscopic cholecystectomy

Background: Pneumoperitoneum to facilitate laparoscopic surgery produces hemodynamic changes that can be harmful for the elderly as well as patients with cardiovascular compromise. Clonidine is an alpha- 2 agonist that can attenuate these changes.Methods: This study of 100 patients was a single blind prospective randomized controlled study. Patients were randomly divided into two groups of 50 each. The clonidine group received 2 microgm/kg iv clonidine in 10 ml normal saline 15 minutes prior to induction. The placebo group received only normal saline. Hemodynamic parameters and incidence of vomiting and shivering were noted.Results: Data was analysed by Pearson’s chi-square test. Clonidine significantly attenuated the rise in heart rate, and the blood pressure. The incidence of postoperative nausea and vomiting was less in the clonidine group. It also reduced shivering.Conclusions: 2 microgm/kg of clonidine iv can be reasonably recommended as a premedicant for laparoscopic procedures in otherwise healthy patients. However further study is required to test its efficacy in patients with compromised cardiovascular function

Title predictors of difficult subarachnoid block

Background: The aim of this prospective randomised study was to evaluate the association of four patient variables with difficulty in subarachnoid block. These variables are age, BMI, quality of bony landmarks and anatomical abnormality of spine. An attempt was made to prepare a difficulty score to predict this difficulty and assess it’s predictive value.Methods: 498 patients scheduled for surgical procedures under subarachnoid block were included. Each patient was assigned a difficulty score according to gradation of four variables. The difficulty was assessed in terms of number of levels, number of  attempts, and completeness of  anaesthesia. Since all these variables operated simultaneously and randomly in each patient, multivariate analysis was used with SPSS version 11.5. ROC curves were used to evaluate the sensitivity and specificity of the score. ROC curves were plotted at scores of 2, 3, 4 and 5 and AUC was compared.Results: This study was successful in preparing a score to predict difficulty in subarachnoid block. A score of 4 or more is indicative of difficulty as far as number of attempts and levels is concerned. However, completeness of anaesthesia could not be predicted with this score.Conclusions: This difficulty score can enable the anaesthetist to predict a difficult spinal puncture. This is a distinct advantage as multiple attempts are not without hazards

Effect of priming principle on the induction dose requirements of propofol in patients undergoing elective surgeries under general anaesthesia

Background: A major disadvantage of rapid induction with propofol is hypotension at a dose of 2 mg/kg. Priming principle is an effective technique to reduce the total induction dose of propofol. The hemodynamic changes are attenuated and the cost is reduced. The frequency and severity of dose related effects also falls.Methods: This study of 100 patients was a prospective randomized controlled study. Patients were randomly divided into two groups of 50 each. The control group received 2mg/kg IV propofol till loss of eyelash reflex. The study or priming group received 30% of the calculated dose followed by the remaining dose after 30 seconds. The total induction dose and hemodynamic parameters were recorded. Incidence of apnoea and fasciculations as well as pain on injection were noted. Analysis of demographic data was done using chi-square test. Comparison between the groups for induction dose and hemodynamic parameters was done using the student ‘t’ test. A p-value of <0.05 was considered statistically significant.Results: The mean induction dose was significantly lower in the study or priming group. The difference in the heart rate was not significant except at 5 minutes after induction. Systolic, diastolic and mean blood pressure was significantly higher in the study group at all times. The incidence of apnoea was greater in the control group while fasciculations were more frequent in the priming group.Conclusions: Priming principle can be effectively applied to propofol to reduce the total induction dose with concomitant attenuation of hypotension. The only disadvantage noted was that fasciculations due to scoline were more pronounced

Comparison of haemodynamic responses in normotensive and hypertensive patients among three intubation devices: macintosh laryngoscope, intubating laryngeal mask airway and lightwand

Background: The pressor response to endotracheal intubation is of special concern, especially in the presence of comorbidities like diabetes, hypertension, obesity and ischemic heart disease (IHD). It is commonly assumed that insertion of laryngeal mask airway (LMA) is associated with lesser hemodynamic fluctuations than conventional laryngoscopy. Also, the lightwand (LW) is believed to provoke a milder pressor response as it does not involve elevation of epiglottis. We decided to evaluate the pressor response to all three devices in normotensive and hypertensive patients.   Methods: We conducted a randomized prospective study consisting of 126 patients posted for surgical procedures under general anesthesia. 63 hypertensive and 63 normotensive patients were randomly assigned to each intubation device: the macintosh laryngoscope (LS), the lightwand (LW), and the intubating laryngeal mask airway (ILMA).The peri-intubation hemodynamic parameters were recorded. Statistical analysis was done with SPSS version 17.0 Inter- and intra-group differences among the hemodynamic variables recorded over time were analyzed by using one-way analysis of variance for repeated measures with bonferroni post-test analysis as appropriate. All quantitative data were expressed as mean±standard deviation (SD). A p-value less than 0.05 was considered statistically significant.Results: All 3 devices (LS, ILMA and LW) are comparable with respect to hemodynamic fluctuations in normotensive patients. However, in hypertensive patients conventional laryngoscopy was associated with greater hemodynamic fluctuations than ILMA or LW. However there was no significant difference in the hemodynamic fluctuations between ILMA and LW.Conclusions: The ILMA and LW may be preferable to LS in hypertensive patients where attenuation of hemodynamic stress response is desired

Title predictors of difficult subarachnoid block

Background: The aim of this prospective randomised study was to evaluate the association of four patient variables with difficulty in subarachnoid block. These variables are age, BMI, quality of bony landmarks and anatomical abnormality of spine. An attempt was made to prepare a difficulty score to predict this difficulty and assess it’s predictive value.Methods: 498 patients scheduled for surgical procedures under subarachnoid block were included. Each patient was assigned a difficulty score according to gradation of four variables. The difficulty was assessed in terms of number of levels, number of  attempts, and completeness of  anaesthesia. Since all these variables operated simultaneously and randomly in each patient, multivariate analysis was used with SPSS version 11.5. ROC curves were used to evaluate the sensitivity and specificity of the score. ROC curves were plotted at scores of 2, 3, 4 and 5 and AUC was compared.Results: This study was successful in preparing a score to predict difficulty in subarachnoid block. A score of 4 or more is indicative of difficulty as far as number of attempts and levels is concerned. However, completeness of anaesthesia could not be predicted with this score.Conclusions: This difficulty score can enable the anaesthetist to predict a difficult spinal puncture. This is a distinct advantage as multiple attempts are not without hazards

Effect of intravenous clonidine premedication in patients undergoing laparoscopic cholecystectomy

Background: Pneumoperitoneum to facilitate laparoscopic surgery produces hemodynamic changes that can be harmful for the elderly as well as patients with cardiovascular compromise. Clonidine is an alpha- 2 agonist that can attenuate these changes.Methods: This study of 100 patients was a single blind prospective randomized controlled study. Patients were randomly divided into two groups of 50 each. The clonidine group received 2 microgm/kg iv clonidine in 10 ml normal saline 15 minutes prior to induction. The placebo group received only normal saline. Hemodynamic parameters and incidence of vomiting and shivering were noted.Results: Data was analysed by Pearson’s chi-square test. Clonidine significantly attenuated the rise in heart rate, and the blood pressure. The incidence of postoperative nausea and vomiting was less in the clonidine group. It also reduced shivering.Conclusions: 2 microgm/kg of clonidine iv can be reasonably recommended as a premedicant for laparoscopic procedures in otherwise healthy patients. However further study is required to test its efficacy in patients with compromised cardiovascular function

Effect of priming principle on the induction dose requirements of propofol in patients undergoing elective surgeries under general anaesthesia

Background: A major disadvantage of rapid induction with propofol is hypotension at a dose of 2 mg/kg. Priming principle is an effective technique to reduce the total induction dose of propofol. The hemodynamic changes are attenuated and the cost is reduced. The frequency and severity of dose related effects also falls.Methods: This study of 100 patients was a prospective randomized controlled study. Patients were randomly divided into two groups of 50 each. The control group received 2mg/kg IV propofol till loss of eyelash reflex. The study or priming group received 30% of the calculated dose followed by the remaining dose after 30 seconds. The total induction dose and hemodynamic parameters were recorded. Incidence of apnoea and fasciculations as well as pain on injection were noted. Analysis of demographic data was done using chi-square test. Comparison between the groups for induction dose and hemodynamic parameters was done using the student ‘t’ test. A p-value of &lt;0.05 was considered statistically significant.Results: The mean induction dose was significantly lower in the study or priming group. The difference in the heart rate was not significant except at 5 minutes after induction. Systolic, diastolic and mean blood pressure was significantly higher in the study group at all times. The incidence of apnoea was greater in the control group while fasciculations were more frequent in the priming group.Conclusions: Priming principle can be effectively applied to propofol to reduce the total induction dose with concomitant attenuation of hypotension. The only disadvantage noted was that fasciculations due to scoline were more pronounced

Lower gastrointestinal bleeding due to hepatic artery pseudoaneurysm following laparoscopic cholecystectomy

Pseudoaneurysm of hepatic artery is a rare but known complication of laparoscopic cholecystectomy (LC). Such pseudoaneurysms may bleed in biliary tree, upper gastrointestinal (GI) tract or peritoneal cavity leading to life-threatening internal haemorrhage. It is very rare for them to present as lower GI bleeding. We report an unusual case of Right hepatic artery pseudoaneurysm developed following LC, which ruptured into hepatic flexure of colon resulting in catastrophic lower GI bleeding. This was associated with partial celiac artery occlusion due to thrombosis. Due to failure of therapeutic embolisation, the patient was subjected to exploratory laparotomy to control haemorrhage. Postoperatively, patient recovered well and was discharged on postoperative day 10. A strong index of suspicion is necessary for early diagnosis of such condition and to limit resultant morbidity. Angioembolisation is the first-line treatment and surgery is indicated in selected cases

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

AbstractBackgroundThere have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.Materials and MethodsBetween January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.ResultsBetween January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9–54). The median number of PDs per surgeon per year was 16 (range 7–38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2–5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3–32.2%), and the median post-operative duration of hospital stay was 16 days (range 4–100 days).ConclusionsThis is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization