Comparison of the conventional CMAC and the D-blade CMAC with the direct laryngoscopes in simulated cervical spine injury—a manikin study

AbstractBackgroundCMAC videolaryngoscope has recently been introduced for videoscope guided intubation. The aim of our study was to compare and evaluate the efficacy of the conventional blade and the angulated D blade of the CMAC videolaryngoscope with the direct laryngoscopes in simulated cervical spine injury patients on the airway manikin.Materials and methodsFollowing power analysis, 33 resident doctors were enrolled to perform endotracheal intubation using all the 4 different laryngoscopes namely the Macintosh laryngoscope, McCoy laryngoscope, conventional CMAC videolaryngoscope and the D blade of the CMAC videolaryngoscopes on the airway manikin in simulated cervical spine injury. The demographic variables of the resident doctors were recorded. The outcomes measured included vocal cord visualization (Cormack–Lehane grading), time taken to intubate, number of attempts for successful intubation and optimizing maneuvers required.ResultsThe use of indirect videolaryngoscopes resulted in better glottic visualization in comparison to the direct laryngoscopes (CL-I) in 20/33 (60.6%) in the Macintosh group, 24/33 (72.7%) in McCoy group, 30/33 in (90.9%) in Vlc group and 32/33 (96.9%) in Vld group. The time taken to intubate averaged to 15.54±2.6 in Macintosh group, 18.90±4.47 in McCoy group, 20.21±7.9 in Vlc group and 27.42±9.09 in Vld group. The 1st attempt intubation success rate was 84.8% (Macintosh), 72.7% (McCoy), 90.9% (Vlc) and, 78.7% (Vld).ConclusionsThe overall performance of the conventional CMAC blade proved to be the best when compared with the D-blade CMAC, Macintosh blade and the McCoy blade for intubation in simulated cervical spine patients by anesthesia residents

Comparative evaluation of propofol, sevoflurane and desflurane for neuroanaesthesia: A prospective randomised study in patients undergoing elective supratentorial craniotomy

Background and Aims: Both inhalational and intravenous anaesthetic agents are being used for neuroanaesthesia. Clinical trials comparing "propofol and sevoflurane" and "desflurane and sevoflurane" have been published. However, the comparison of all the three anaesthetics in neurosurgical patients has not been done. A randomised clinical study was carried out comparing propofol, sevoflurane and desflurane to find the ideal neuroanaesthetic agent. Methods: A total of 75 adult patients undergoing elective craniotomy for supratentorial tumours were included in the study. The patients were induced with morphine 0.1 mg/kg and thiopentone 4-6 mg/kg. Neuromuscular blockade was facilitated with vecuronium. The patients were randomised to receive propofol, sevoflurane or desflurane along with nitrous oxide in oxygen for maintenance of anaesthesia. The neuromuscular blockade was reversed following the surgery once the patients opened eyes or responded to verbal commands. The three anaesthetics were compared for their effects on haemodynamics, brain relaxation and emergence characteristics. Results: The mean arterial blood pressure during anaesthesia was comparable among the groups. The patients receiving sevoflurane had faster heart rates intraoperatively when compared to desflurane (P 0.05). The time to response to verbal commands were significantly prolonged with use of sevoflurane (8.0 ± 2.9 min) when compared to propofol (5.3 ± 2.9 min) and desflurane (5.2 ± 2.6 min) (P = 0.003). However, the time to emergence and the number of patients who had early emergence ( 0.05). The quality of emergence (coughing and emergence agitation), as well as postoperative complications, were also comparable among the three groups. Conclusions: All the three anaesthetic agents-propofol, sevoflurane and desflurane appear comparable and acceptable with regard to their clinical profile during anaesthesia in patients undergoing elective supratentorial surgeries

Comparison of bispectral index and end-tidal anaesthetic concentration monitoring on recovery profile of desflurane in patients undergoing lumbar spine surgery

Background and Aims: Several techniques have evolved over time to monitor depth of anesthesia and ensure enhanced recovery. This randomized double-blinded trial was designed to compare bispectral index (BIS) or end-tidal anaesthetic concentration (ETAC) monitoring on the recovery characteristics of patients undergoing thoracolumbar spine surgeries. Methods: Seventy American Society of Anesthesiologist I–II patients of either sex were randomized to Group B – BIS-guided protocol, Group E – ETAC-guided protocol, or Group S – Standard protocol. After intravenous induction, anaesthesia was maintained with desflurane in O2/N2O (50:50) mixture. In BIS, ETAC and Standard groups, inspired end-tidal desflurane concentration was varied to achieve BIS of 45–55, 0.8–1.0 age-corrected minimum alveolar concentration, and haemodynamic parameters within 20% of the baseline, respectively. Time to eye opening (emergence time, the primary outcome), time to extubation, and time to name recall from the discontinuation of the anaesthetic agent were recorded. Incidence of nausea, vomiting, and total analgesic consumption was noted for 24 h. Results: Emergence time (mean ± SD) in ETAC (5.1 ± 1.53 min) and BIS (5.0 ± 2.12 min)-guided groups was significantly lower than Standard group (7.5 ± 2.90 min). Extubation time in ETAC (6.3 ± 2.22 min) and BIS-guided group (6.5 ± 1.78 min) was significantly lower than Standard group (9.0 ± 3.20 min) (P < 0.001). Time to achieve fast track score of more than 12 was significantly less in BIS-guided group (13.12 ± 2.59 min). Conclusion: ETAC-guided anaesthesia is comparable to BIS-guided anaesthesia in achieving early recovery

Efficacy and safety of combined spinal: Epidural versus epidural technique for labor analgesia in parturients with rheumatic valvular heart disease

Background: Hemodynamic changes induced by labor pain and apprehension in addition to physiological changes may pose risk to parturients with rheumatic heart disease (RHD). Therefore, it is important to provide adequate pain relief during labor in these patients. We planned this study to compare the efficacy and safety of epidural (E) versus combined spinal - epidural (CSE) for labor analgesia in parturients with rheumatic valvular heart disease. Methods: Twenty-five parturients with RHD included in this study were randomized to one of the two groups - E group (n = 12), received 6 mL of 0.0625% bupivacaine with 25 μg fentanyl or CSE group (n = 13), received 25 μg of fentanyl with 1.25 mg bupivacaine diluted to 1 mL in subarachnoid space. Afterward, a continuous infusion of 0.1% bupivacaine with 2 μg/mL fentanyl was started at 6-8 mL/h. Primary outcome, analgesic efficacy, was assessed by visual analog scale (VAS) for pain. VAS ≤ 3 was considered as effective analgesia. Rescue analgesia in the form of epidural bolus was given if VAS > 3. Results: Demographic characteristics of the patients were comparable. Mitral stenosis was the predominant valvular lesion. The VAS at which the parturients received analgesia was comparable. The mean time to achieve effective analgesia was significantly faster in CSE group (4.46 ± 0.87 min) compared with group E (15.09 ± 5.7 min) (P < 0.001). Significantly lower median pain scores were recorded until the initial 15 min in CSE group. Afterward, median VAS for pain was comparable between the groups. VAS for pain was significantly low at all time intervals than baseline in both the groups. Maternal satisfaction and incidence of cesarean rate and complication were comparable between the groups. Conclusion: Both epidural and CSE are equally effective and safe for labor analgesia in parturients with rheumatic valvular heart disease. However, CSE technique provides a faster onset of analgesia

An Acetazolamide Based Multimodal Analgesic Approach Versus Conventional Pain Management in Patients Undergoing Laparoscopic Living Donor Nephrectomy

Choice of an appropriate anaesthetic technique and adequate pain relief during laparoscopic living donor ne-phrectomy (LDN) is likely to make the procedure more appealing to kidney donors. Various analgesic regimens proposed to relieve pain after laparoscopic surgery include: opioids, non-opioid analgesics followed by opioids for the breakthrough pain and intra-peritoneal normal saline irrigation and instillation of local anaesthetics at surgical sites. Thorough literature review and medline search did not reveal any study where a combination of orogastrie aeetazolamide along with intraperitoneal saline irrigation and bupivacaine instillation techniques have been tried in these patients. In a prospective, double blind, randomized trial, eighty healthy adults undergoing LDN under general anaesthesia were enrolled to compare the efficacy of an acetazolamide based multimodal analgesic approach (Group A) with conventional pain management (Group B). Donors′ demographics, intra-operative variables, early allograft function and recovery characteristics were evaluated for 72 hours. The primary end points were postoperative pain intensity on a visual analog scale and the incidence of shoulder tip pain (SIP). The secondary end points included the latency of the rescue analgesia request rate, total analgesic consumption and patient satisfaction. Consistently lower mean pain scores were observed in Group A (p < 0.03 for visceral pain). Frequency as well as the total dose of rescue analgesics administered was significantly less in Group A (p=0.001). Twelve patients (30.7%) in Group B complained of STP compared to three (7.5%) in Group A(p=0.025). Shoulder pain also presented earlier (8 hours versus 12 hours) and persisted for longer period in Group B (72 hours versus 48 hours, p 0.025). To conclude, a multimodal analgesic approach consisting a combination of orogastric acetazolamide, intraperito-neal saline irrigation and use of bupivacaine in the operated renal fossa, pfannenstiel incision and laparoscopic port sites provide significant reduction in postoperative pain after LDN

Awareness of bispectral index monitoring system among the critical care nursing personnel in a tertiary care hospital of India

Background: Bispectral index monitoring system (BIS) is one of the several systems used to measure the effects of anaesthetic and sedative drugs on the brain and to track changes in the patient′s level of sedation and hypnosis. BIS monitoring provides information clinically relevant to the adjustment of dosages of sedating medication. It can help the nursing personnel in preventing under- and over sedation among intensive care unit (ICU) patients. Objective: The present study was conducted to assess the knowledge of nursing personnel working in the ICU regarding BIS. Methods: Fifty-four subjects participated in the study. A structured questionnaire was developed to assess the knowledge of the nursing personnel regarding BIS. Focus group discussions were held among the nursing personnel to know their views regarding BIS. Results: Mean age (years) of the subjects was 30.7΁7.19 (21-47) years, with a female preponderance. Although the use of BIS in ICU is not common, majority (94.44%) were aware of BIS and its purpose. 79.62% of the subjects knew about its implication in patient care. The mean knowledge score of the subjects was 11.87΁2.43 (maximum score being 15). Conclusion: There exists an awareness among the critical care nursing staff in our institution regarding BIS and its clinical implications. Its use in the critical care setting may benefit the patients in terms of providing optimal sedation

Serum cortisol level in indian patients with severe sepsis/septic shock

Background: The relationship between cortisol level and sepsis is not known in Indian patients of severe sepsis/septic shock. Aims: The study was done to determine the optimal range of cortisol levels, defining the adrenocortical response, and predicting the mortality, if possible, in the above type of patients. Settings and Designs: The study was a single-centered prospective cohort study, conducted in a tertiary referral center, North India. Materials and Methods: Sixty patients with severe sepsis (n = 30) and septic shock (n = 30) were recruited. Basal and postcosyntropin (1 μg)-stimulated cortisol levels were measured, and all patients were closely monitored with daily assessments of clinical and laboratory variables. Western diagnostic criteria were followed for defining adrenal insufficiency (AI). The end point was the survival assessed at day 28 or death, whichever came earlier. Results: The mean basal (T0) and poststimulation (T30) cortisol levels were 31.77 ± 15.9 μg/dL and 37.58 ± 17.31 μg/dL, respectively. In all sepsis patients, 48.33% qualified as AI at T0 ≤ 24 μg/dL, 61.67% at delta cortisol (Δ = T30-T0) ≤7 μg/dL, and 78.33% at Δ ≤9 μg/dL. Using receiver operating characteristic curve, the area under the curve (AUC) was 0.4954, signifying poor prediction to death. Conclusions: Indians have completely different characteristics of cortisol levels in sepsis patients, in comparison to the Western data. They have higher range of basal cortisol levels, higher percentage of AI, and an inability to predict mortality with the cortisol levels. Hence, there is requirement of an international study to confirm the dichotomy of the results