Effects of Crystalloid Preloading (20 ml/kg) on Hemodynamics in Relation to Postural Changes in Patients Undergoing Neurosurgical Procedures in Sitting Position

Background: Hemodynamic disturbances are common during positioning the patients from supine to sitting for neurosurgical procedures. The reported incidence of hypotension varies from 5% to 32%. The aim of the study was to study the effect of crystalloid preloading on hemodynamic parameters during positioning the patient from supine to sitting position. Materials and Methods: In this prospective observational trial, 20 patients were enrolled. Two patients had a patent foramen ovale on transesophageal echocardiography and were excluded from the study. All the patients received 20 ml/kg of crystalloid (Ringer's lactate) before initiation of positioning. Physiological hemodynamic parameters such as heart rate, mean arterial pressure, central venous pressure, cardiac output (CO), stroke volume variation (SVV), cardiac index (CI), stroke volume (SV), and maximum and minimum inferior vena caval diameter (IVCD) were recorded after induction, during positioning at 30°, 60° inclination of the operating table and after the final sitting position. Results: Hemodynamic parameters were well maintained during positioning of the patients from supine to sitting position. Crystalloid preloading prevented the hypotension during positioning. There were no significant changes in hemodynamic parameters such as CO, SVR, SVV, CI, and SV. We did not find any correlation with changes in IVCD with changes in CO. Conclusion: A volume of 20 ml/kg of crystalloid preloading before positioning the patient from supine to sitting position maintains the hemodynamic stability and avoids the vasopressor requirement

Non-opioid versus Opioid Peri-operative Analgesia In Neurosurgery (NOPAIN): Study protocol for a multi-centric randomised controlled trial

Background and Aims: Many patients suffer from post-operative pain after neurosurgery despite using intra-operative opioids. Opioid side effects are problematic in neurosurgical patients. Hence, non-opioid alternatives for the management of nociception and pain are needed. Previous studies comparing opioids with non-opioids in the neurosurgical population were few, from single centres, of small sample sizes and were equivocal in findings, which prevented change in clinical practice. To overcome these limitations, we are conducting a multi-centre trial with objectives to compare intra-operative rescue opioid requirements and post-operative pain scores (primary objectives), adverse events, quality of recovery from anaesthesia, quality of sleep and patient satisfaction during hospital stay, and persistent post-surgical pain and quality of life at 3 and 6 months (secondary objectives) in patients receiving opioid and non-opioid analgesia for brain tumour surgeries. Methods: This study protocol describes the methodology of a multi-centre randomised controlled trial. Ethics committee approval has been obtained from all five centres, the trial has been registered with the Clinical Trial Registry- India, and insurance has been obtained for this investigator-initiated funded study. In patients undergoing supra-tentorial brain tumour surgery (population), we will compare fentanyl (intervention) 1 μg/kg/h with dexmedetomidine (comparator) 0.5 μg/kg/h administered during surgery with regards to intra-operative rescue opioid requirement and post-operative pain (primary outcomes). Results: We describe the study protocol of the multi-centre trial (protocol version 2, dated 29/01/2022). The first patient was recruited on 19/10/2022, and we will complete recruitment before March 2024. Conclusion: We expect our study to establish dexmedetomidine as an effective non-opioid analgesic vis-à-vis opioids in the neurosurgical population

Evaluation of simple pre-determined length insertion technique (SPLIT) with conventional method for oral fibreoptic intubation: A randomised cross-over study

Background and Aims: The difficulty during flexible fiber-optic bronchoscopy (FOB) guided tracheal intubation could be because of inability in visualising glottis, advancing and railroading of endotracheal tube. Several methods are available for visualising glottis, but none is ideal. Hence, this randomised controlled study was designed to evaluate the simple pre-determined length insertion technique (SPLIT) during oral FOB. Methods: Fifty-eight patients were randomised into Group C and Group P. General anaesthesia was maintained with sevoflurane and oxygen in spontaneous respiration. In Group C, conventional flexible fiberoptic laryngoscopy was done followed by SPLIT and vice versa in Group P. The time to visualise the glottis (T1), from glottic visualisation to pass beyond glottis (T2) and from incisors to pass beyond the glottis (T3) were noted from the recorded video. The time interval was analysed using Wilcoxon matched pairs test and Mann–Whitney U-test. Results: The T1was significantly less in SPLIT as compared to conventional technique (13 [10, 20.25] vs. 33 [22, 48] s). The T3was significantly less in SPLIT (24.5 [19.75, 30] vs. 44 [34, 61.25] s). The T1by SPLIT was comparable between residents and consultants (P = 0.09), whereas it was significantly more among residents than the conventional technique. The SPLIT was preferred by 91.3% anaesthesiologists. Conclusion: The SPLIT significantly lessened the time to visualise the glottis than conventional technique for FOB. The SPLIT was the preferred technique. Hence, we suggest using the SPLIT to secure the airway at the earliest and also as an alternative to conventional technique

Effect of immobilised cervical spine on oropharyngeal sealing pressure with Ambu AuraGain™ Supraglottic airway: A randomised crossover trial

Background and Aims: Ambu® AuraGain™ laryngeal airway (AuraGain) is one of the newer supraglottic airway device introduced in 2014. Cervical spine stabilisation with hard cervical collar makes insertion of supraglottic airways and tracheal intubation difficult. This study was conducted to investigate whether the presence of a cervical collar affects the oropharyngeal sealing pressure (OSP) and fibreoptic view of the glottis (Brimacombe score) in airways secured with the AuraGain. Methods: The study was a randomised crossover trial. Thirty five ASA 1-3 patients undergoing elective surgery under general anaesthesia were recruited for the study. In each patient AuraGain was inserted twice in a crossover manner once with and once without a hard cervical collar in situ, with the sequence of insertion randomised. During each insertion of AuraGain the OSP, fibreoptic view of the glottis, insertion parameters, ventilator data and complications were noted. Results: The mean OSPs in both the groups were similar with no significant difference (29.6 ± 3.7 cmH2O without collar and 30.1 ± 3.1 cmH2O with collar [P = 0.310]). The fibreoptic view of glottis was also similar in both groups. The insertion with collar was more difficult than without collar. The number of attempts for successful insertion was same in both the groups. The time taken for appropriate placement of LMA was significantly prolonged in patients with collar. Conclusions: We conclude that the Ambu AuraGain can be used to provide effective ventilation in patients whose cervical spine is immobilised with a hard cervical collar

Comparison of different regimens of intravenous dexmedetomidine on duration of subarachnoid block

Background and Aims: Many studies have studied the effect of intravenous dexmedetomidine on the prolongation of the duration of the subarachnoid block (SAB). These studies had administered dexmedetomidine using different regimens. This study was designed to find out the suitable regimen with maximum advantages and minimum disadvantages. Material and Methods: Ninety-three ASA 1 and 2 patients scheduled to undergo surgeries under SAB were randomly allocated into three groups namely B, M, and BM. After SAB, Group B received 0.5 μg/kg of dexmedetomidine bolus over 15 min, Group M received 0.5 μg/kg/h of dexmedetomidine infusion until the end of surgery, Group BM received both bolus and infusion. Results: The time to achieve T10 sensory level (SL) was significantly faster in the Groups B and BM than in the Group M. Maximum block height achieved was T4 and was same in all the groups. The Time to achieve maximum SL and Bromage 3 was comparable in all groups. The two-segment regression time and time to reach Bromage 0 was significantly higher in Groups M and BM than Group B. The time for a first request of analgesia was similar in Groups M and BM. The maximum sedation attained in all groups was Ramsay Sedation Score of 3. Side effects such as bradycardia, hypotension, and desaturation were comparable between the groups. Conclusion: We conclude that the continuous infusion of dexmedetomidine results in more advantages than just a bolus dose. Therefore, we suggest using only the maintenance dose of intravenous dexmedetomidine after subarachnoid blockade for prolonging the duration and achieving sedation

Effect of low dose tranexamic acid on intra-operative blood loss in neurosurgical patients

Background: Blood loss is often a major complication in neurosurgery that requires transfusion of multiple units of blood. The purpose of this study was to assess the effect of tranexamic acid (TXA) on intraoperative blood loss and the need for blood transfusion in patients undergoing craniotomy for tumor excision. Materials and Methods: A total of 100 patients aged 18-60 years, with American Society of Anesthesiologists physical Status 1 and 2 scheduled to undergo elective craniotomy for tumor excision were enrolled. Patients received 10 mg/kg bolus about 20 min before skin incision followed by 1 mg/kg/h infusion of either TXA or saline. Hemodynamic variables, intravenous fluid transfused, amount of blood loss and blood given were measured every 2 h. Laboratory parameters such as serum electrolytes and fibrinogen values were measured every 3 h. On the 5 th postoperative day hemoglobin (POD Hb5), Hb estimation was done and the estimated blood loss (EBL) calculated. Patients were also monitored for any complications. Results: The Mean heart rate in TXA group was significantly lower compared with the saline group. Mean arterial pressure and fibrinogen levels were higher in TXA group. The mean total blood loss in the TXA group was less than in the saline group. Blood transfusion requirements were comparable in two groups. The EBL and POD5 Hb were comparable in two groups. Conclusion: Even though, there is a significant reduction in the total amount of blood loss in TXA group. However, there was no reduction in intraoperative transfusion requirement