Assessment of haemodynamic stability with intubating dose of intravenous rocuronium bromide versus vecuronium bromide in predominantly stenotic valvular cardiac surgery patients

Background: In the purely or predominantly mitral stenotic heart surgeries, the principal haemodynamic goals are to maintain a sinus rhythm and avoiding tachycardia. Thus rapid airway control and hemodynamic stability are vital for successful anaesthetic management of patients undergoing the cardiac surgeries. In such patients, muscle relaxants play a pivotal role for achieving good hemodynamic stability. Hence, this study was conducted to evaluate the hemodynamic stability of rocuronium bromide i.v. vecuronium bromide.Methods: The study conducted was randomized prospective double blind study in 60 adult patients (30 in each group) undergoing elective cardiac valvular surgery. Each group received either intubating dose of Rocuronium (0.6 mg/kg body weight) or intubating dose vecuronium (0.1 mg/kg body weight) intravenously after receiving sedation and analgesia. Hemodynamic parameters like heart rate, systolic and diastolic blood pressure, mean arterial pressure and central venous pressure were recorded at baseline 10 minutes after sedation /analgesia at induction, laryngoscopy and at  intubation. Any side effects during intubation were noted.Results: Intubating doses of either Rocuronium or vecuronium are not associated with any haemodynamic adverse effects. Also there were no statistically significant (p<0.05) differences between both these groups, in any of the variables at any time.Conclusions: The present study showed that Rocuronium had maintained excellent cardiovascular stability for the dose given to the patient. There was no statistically significant increase in heart rate, systolic, diastolic and mean arterial blood pressure after administration of Rocuronium as compared to vecuronium in the study.

A comparative study of volume control ventilation versus pressure control ventilation in patients of trauma

Background: Trauma patients may require mechanical ventilation secondary to the respiratory centre depression or acute respiratory distress syndrome (ARDS). It has become increasingly accepted that mechanical ventilation, although often life-saving, can contribute to lung injury. This concept has led to implementation of lung protective ventilation strategies.Methods: This is a prospective, double blind, comparative study in which sixty patients of intubated trauma patients on mechanical ventilation expected at least for five days are included. They were divided in group V where patients were put on volume control ventilation for four days and group-P where patients were put on volume control for two days and pressure control for next two days, after initial stabilization. Each patient was evaluated for ventilation parameters (partial pressure of oxygen, partial pressure of carbon dioxide, peak inspiratory pressure), chest X ray findings and outcome of the patient, keeping the hemodynamic stability and medications same in all patients of both groups.Results: The demographic data like age, weight, and sex were comparable in both volume and pressure control groups.. Baseline ventilation parameters were compared between the groups at every eight hours. During the study we found that there was significant and better oxygenation in pressure control ventilation than volume, less increase in peak inspiratory pressure in pressure controlled ventilation than volume controlled. Other parameters like partial pressure of carbon dioxide also showed less increase in pressure control ventilation. Chest X ray finding showed that the data is comparable and statistically not significant in both the groups. The outcomes of the patients were good in pressure control mode of ventilation than volume control mode and the data was statistically significant.Conclusions: We conclude a better compliance of patients and good respiratory outcome on pressure control than volume. It has better lung compliance with respect to partial pressures of O2 and CO2 and peak inspiratory pressures than the volume control

A prospective randomised double-blinded study of intranasal midazolam atomizer spray for procedural sedation in paediatric patients

Background: Premedication prior to anaesthesia in children provides anxiolysis, facilitates parenteral separation and lessens adverse psychological effects on young minds. The present study was designed to study the safety, acceptability and degree of sedation by intranasal midazolam spray in children undergoing short procedures like endoscopy and CT scan. Methods: Sixty children scheduled for CT scan or endoscopy were randomly divided in to two groups. Thirty patients received intranasal midazolam spray 0.2 mg/kg, 20 minutes prior to procedure (group M) while other thirty patients received intra-nasal 0.9% normal saline spray (group C). Vital parameters such as heart rate (HR), systolic and diastolic blood pressure, respiratory rate (RR), SpO2, ramsay sedation score (RSS) and anxiety score level was observed and recorded prior to the premedication and then every 5 minutes till the end of the procedure. Parenteral separation and behaviour of the patient while entering the procedure room was also evaluated in both groups.Results: The mean heart rate, systolic blood pressure, respiratory rate, oxygen saturation were comparable between groups M and C. The mean diastolic blood pressure was significantly lower in group M as compared to group C. RSS and anxiety level score achieved were significantly higher in group M thereby facilitating easy parenteral separation.Conclusions: We can thereby say that administration of preservative free intranasal midazolam atomizer spray in dose of 0.2mg/kg as premedication in paediatric patients produces satisfactory level of sedation and anxiolysis with minimal adverse effects

A comparative study of nebulized versus intravenous lignocaine to suppress the haemodynamic response to endotracheal suction in patients on mechanical ventilation

Background: Cardiovascular response to tracheal suction is decreased by intravenous lignocaine. Tracheal suction is a powerful stimulus that causes intense haemodynamic changes in patients on mechanical ventilation. In the present study, we compared the effect of nebulized and intravenous lignocaine on haemodynamic response to tracheal suctioning in patients on mechanical ventilation through an endotracheal tube.Methods: A prospective randomized cross over study was conducted in Lokmanya Tilak Municipal Medical College and Government Hospital, Sion, Mumbai, India during the period of January 2012 to September 2013. Sixty patients requiring tracheal suction through an endotracheal tube received 1.5 mg/kg of lignocaine in the nebulized form or as an intravenous injection on two different occasions. Heart rate (HR), mean arterial pressure (MAP), systolic and diastolic blood pressure (SBP and DBP) and peripheral capillary oxygen saturation (SPO2) were recorded at baseline, after the administration of lignocaine, after two successive suctions and once in two minutes for the next 16 minutesResults: In the present study, SPO2 decreased in response to ETT suctioning in both the study groups as compared to the pre-suctioning value. However the changes in the SPO2 were not significant when compared between the groups. Changes in HR, SBP, DBP and MAP were not significantly different between the two routes of lignocaine administration.Conclusions: From the present study, we can conclude that the abolition of haemodynamic response to tracheal suction is similar with both intravenous and nebulized lignocaine. But the return of MAP towards baseline value was observed to be earlier with nebulized lignocaine than with intravenous lignocaine which favours use of nebulized lignocaine over intravenous lignocaine. With built-in nebulizer facility in the current intensive care ventilators, this technique should be easy, more effective and assure better haemodynamic stability than intravenous lignocaine during tracheal suction.

A comparative study of endotracheal intubation as per intubation difficulty score, using Airtraq and McCoy laryngoscopes with manual-in-line axial stabilization of cervical spine in adult patients

Background: The different types of laryngoscopes have been invented to improve the laryngoscopic view of the glottis in normal and difficult airway which helps anaesthesiologists to safeguard the airway during anaesthesia. Patients with cervical spine injury have deleterious compression forces on the spinal cord and that should be avoided by taking protective measures which include application of rigid collar, a forehead tape and manual-in-line axial stabilisation (MILAS). The objective of the study was to evaluate the ease of intubation with Airtraq and McCoy laryngoscope as per intubation difficulty score (IDS) with manual-in-line axial stabilization of cervical spine.Methods: In this prospective observational study, 100 adults of ASA I-II, aged 18 to 60 years, with Mallampati classification I and II, undergoing elective surgery under general anaesthesia with oral endotracheal intubation were included. Fifty patients were intubated using Airtraq (Group A). Another fifty patients were intubated using McCoy laryngoscope (Group B). During intubation with both devices, neck was immobilized using MILAS. Ease of intubation as per IDS, insertion of device as per Likert scale, duration of laryngoscopy and intubation, number of attempts, haemodynamic changes and complications were compared for both devices.Results: Demographic characteristics were comparable in both groups. There is no significant difference observed in the heart rate,  systolic and diastolic blood pressure during device insertion, intubation and up to 10 minutes after intubation in Airtraq and McCoy group. There is statistically significant difference in number of intubation attempts, duration of laryngoscopy and intubation in both groups. As per Likert scale, ease of insertion of device was statistically insignificant between two groups. McCoy group had statistically significant higher intubation difficulty scores (2.9±0.68) compared to Airtraq group (0.56±0.54) (p=0.000). All patients in Airtraq group showed Cormack and Lehane grade 1, while 30% patients in McCoy group had Cormack and Lehane grade more than 1.Conclusions: The Airtraq facilitates the ease of intubation by providing a better view of the larynx as compared to McCoy laryngoscope in patients with manual-in-line axial stabilization of cervical spine.

A study of comparing single dose granisetron with combination of granisetron with dexamethasone in preventing postoperative nausea vomiting in laparoscopic cholecystectomies

Background: Postoperative nausea and vomiting (PONV) remains a vexing problem despite of advances in anaesthesia care. PONV is distressing adverse effect after anaesthesia and surgery, resulting in significant morbidity due to acute discomfort associated with emetic symptoms and longer stays in the recovery room or unexpected hospital admission in ambulatory settings.Methods: A prospective, randomized, double blind comparative study was conducted to compare the efficacy and adverse effects of injection granisetron 40µg/kg as a single dose and injection granisetron in two different doses (20µg/kg and 40µg/kg) in combination with dexamethasone 160µg/kg for prevention of postoperative nausea and vomiting in patients undergoing general anaesthesia for elective laparoscopic cholecystectomy.Results: Nausea and vomiting were observed postoperatively at 0, 1, 2, 4, 8, and 24 consecutive hours after patient responded to verbal commands. Intensity of nausea graded verbally with an eleven point score (0-10) with those patients who scored their nausea as zero were termed nausea free, and 10 being most severe. Nausea scores when patient complains of nausea & if patient demand rescue antiemetic for nausea was noted down along with adverse effects if any. The data was analysed by ANOVA followed by unpaired‘t’ test, Chi-square/Fischer exact test or Kruskal Wallis Test.Conclusions: Granisetron as a single agent in dose 40µg/kg is effective as prophylactic antiemetic in preventing PONV in laparoscopic cholecystectomy whereas addition of dexamethasone 160µg/kg to granisetron significantly increases antiemetic efficacy of the granisetron in both the doses i.e. 20µg/kg and 40µg/kg without increasing any side effect. Granisetron 40µg//kg+injection dexamethasone 160µg/kg is best for antiemetic prophylaxis in highly emetogenic surgeries like laparoscopic cholecystectomy.  Granisetron 20µg/kg + injection dexamethasone can be cost effective alternative for routine antiemetic prophylaxis compared to granisetron 40µg//kg and granisetron 40µg//kg+ injection dexamethasone for all patients undergoing laparoscopic cholecystectomy.

A prospective, randomized, double blind, placebo controlled clinical trial to study efficacy and safety of benzydamine 0.15% gargles in prevention of postoperative sore throat

Background: Postoperative sore throat (POST) is an undesirable outcome of general anesthesia. The aim of the study was to evaluate the effectiveness of benzydamine preoperative gargles in reducing the incidence and severity of POST.Methods: A randomized double blind prospective study involving 200 adult male and female patients was performed to assess the incidence of sore throat, cough and hoarseness of voice following tracheal intubation. The patients were randomly divided into two groups (group B and group C) of 100 each. Group B patients received benzydamine 0.15% gargles while group C received placebo. Patients were asked to gargle for 30 seconds, five minutes before induction of anesthesia. The patients were examined for sore throat, cough and hoarseness of voice at intervals of 0, 2, 4, and 24 hours post-extubation.Results: The incidence of POST was significantly high (p&lt;0.05) in the group C (controls) as compared to group B (cases) at all the durations of time after extubation. The peak incidence was noted at 0 and 2 hours post extubation, in both the groups, where 89% in group C and 47% reports of sore throat in group B were observed. The benzydamine group B had no evidence of sore throat at 24 hours duration whereas group C had 36% of patients who still complained sore throat. The incidence and severity of hoarseness of voice was found to be significantly low in group B at all the times as compared to group C (p&lt;0.05).Conclusions: A simple technique of gargling performed preoperatively with benzydamine hydrochloride was effective in reducing POST with no evidence of any side effects.

Prospective, randomized, double blind, placebo controlled clinical study to different doses of ketamine for prevention of shivering during spinal anaesthesia

Background: Ketamine has better effect than other drugs like pethidine, fentanyl, clonidine, tramadol, midazolam in prevention of shivering during anaesthesia and has a role in thermoregulation by different means. The objective of this study was to evaluate the safety, efficacy of Ketamine injection and to compare the different doses (0.25 mg/kg and 0.5 mg/kg) of inj. Ketamine in prevention of shivering in operative patients under spinal anaesthesia.Methods: The present study was a prospective, randomized, double blinded and clinical study conducted in L.T.M.M.C & L.T.M.G.H, Mumbai, India during January 2012 to September 2013. 120 patients with American Society of Anesthesiologist (ASA) physical status of I or II, between the age of 18 – 65 years of either sex and height 150-170 cms were randomly selected and included in the study as per eligibility.Results: The study suggests that prophylactic administration of injection Ketamine at doses of 0.25 mg/kg and 0.5 mg/kg was producing a significant antishivering effect but an incidence of sedation and hallucination was observed in the Ketamine 0.5 mg/kg receiving group throughout the perioperative period.Conclusions: From this study we can conclude that prophylactic dose of Ketamine 0.25 mg/kg i.v. has lesser side effects comparison to Ketamine 0.5 mg/kg i.v. in prevention of shivering in patients, undergoing surgical procedure under spinal anaesthesia

Intrathecal clonidine for post-operative pain relief in lower abdominal surgeries

Background: Spinal anaesthesia is preferred method for surgeries of lower half of the body due to its efficacy, rapidity, minimal side effects. Generally bupivacaine is given as an spinal anaesthetic agent because of its  analgesic effect in the initial postoperative period. For additional analgesic effect particularly for lower limb surgeries now-a-days it is recommended to add an adjuvant inj.clonidine. Hence the present study is aimed to compare the effects of combination of clonidine with bupivacaine and bupivacaine alone.   Methods: The study  was prospective, randomized, double blinded and controlled study. 90 indoor patients between age group of 18-70 years of either sex of ASA physical status I/II who were to undergo lower abdominal surgeries including gynaecological, orthopaedic and surgical were selected for the study. Parameters like post operative analgesic effects, onset, peak level and two segment regression of sensory block and onset, peak and recovery of motor block, time of rescue analgesia and  various side effects were assessed on administration of clonidine at a dose 60 mcg intrathecally and 75 mcg of bupivacaine and comparing the same with bupivacaine hydrochloride alone.Results: Of 90 patients, the mean age group of the patients was 34, mean weight was 56 kgs and average height was 106 cm. The number of males was 63 and females were 27. Patients receiving bupivacaine 0.5% and different doses of clonidine 60 mcg and 75 mcg (group B and group C) respectively produced significant sensory and motor blockade, increases in time of rescue analgesic with lesser side effects compared to bupivacaine alone receiving group. When compared group B and group C, group receiving highest dose of clonidine produced good results compared to group B.Conclusions: It is concluded that patients receiving bupavacaine with clonidine at different doses produced significant anaesthetic, analgesic effect and lesser side effects compared to bupavacaine alone receiving group

A comparative study of combined spinal epidural anaesthesia and general anaesthesia in patients undergoing percutaneous nephrolithotomy

Background: Our primary aim was to study the efficacy, safety, hemodynamic stability, postoperative pain relief, and complication with combined spinal epidural anaesthesia (CSE) and to compare it with general anaesthesia (GA) for percutaneous nephrolithotomy (PCNL).  Methods: The present study was a prospective, randomized, open, controlled trial to compare the effects of CSE and GA in patients undergoing PCNL. Study was carried out in 100 adult patients, who were randomly divided into two groups of 50 each, Group GA and Group CSE. Post-operative pain relief and amount rescue analgesia required were noted. Postoperatively samples were collected for haemoglobin and arterial blood gases. Incidence of complications were noted and compared among both the groups.Results: Mean arterial pressure in CSE group was less compared to GA group during the procedure. 30 % patients in group GA required first rescue analgesia within first hour of completion of surgery whereas no patient in group CSE required analgesia within first hour indicating better pain relief in CSE group. Mean haemoglobin and the fall in haemoglobin between the groups were comparable. 48.0% of the cases among GA group and 14.0% of the cases among CSE group had postoperative nausea and vomiting. Mean pH in GA group was 7.33±0.05 and in CSE group was 7.36±0.04. There was one case of hydrothorax post operatively.Conclusions: We conclude that CSE is a safe alternative to GA for PCNL with better pain relief, less PONV. Hypotension due to sympathetic blockade is always a possibility