Current Issue Volume 2, Number 2 , July-December 2017

EDITORIAL
SK Gvalani

Simulation: The Way Ahead!

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:iv]



Medical simulation originated in ancient times when models of human patients built-in clay and stone were first used to demonstrate the clinical features of disease in humans.1 Modern medical simulation began in the 1960s with the manufacture of Resusci-Anne, the most widely used mannequin of the twentieth century.


ORIGINAL RESEARCH
Swagat Pattajoshi, Aparna A Nerurkar, Bharati A Tendolkar

A Cross-sectional Observational Analysis of Preoperative Blood Glucose Levels in Nondiabetic Patients presenting for Surgery

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:29-33]



Introduction: Abnormal blood glucose levels alter the course and result of surgery. This study aims to quantify the incidence of hypoglycemia or hyperglycemia in the preoperative period and to assess the impact of duration of nil per os (NPO), age, intravenous fluids (IVFs), blood transfusion, severity of pain and anxiety, and steroid or antibiotic administration on preoperative blood glucose levels in nondiabetic patients.

Materials and methods: The NPO duration, age, IVF, blood transfusion, pain and anxiety score, steroid and antibiotic administration were noted in 1,000 nondiabetic patients presenting for both elective and emergency surgery. Blood glucose level was measured before induction of anesthesia by capillary finger-prick method. The values of blood glucose levels were analyzed for correlation with above-mentioned parameters.

Results: Overall incidence of hypoglycemia was found to be 23.3%. About 27.2% of patients including 34.95% children posted for elective surgery and 33.37% of patients including 8.73% children posted for emergency surgery group were hypoglycemic. The incidence of hyperglycemia was 1.51 and 1.08% for adults in elective and emergency category respectively. Age showed widely varied association to preoperative blood glucose levels; blood glucose levels increased with age in male patients, with patients aged between 18 and 40 years admitted for emergency surgery (p = 0.006), but decreased with age in patients older than 60 years irrespective of gender and type of surgery (p = 0.014). The preoperative blood glucose levels increased with higher preoperative pain and anxiety (p = 0.05) and administration of steroids (p = 0.00043). Similarly, with increase in duration of NPO, preoperative blood glucose levels decreased in adult females (p = 0.000) and males over 40 years (p = 0.049), both admitted for emergency surgery. Only preoperative normal saline (NS; p = 0.001), 6% hydroxyethyl starch (HES; p = 0.043), Isolyte P (p = 0.000), and blood transfusion (p = 0.05) showed significant correlation.

Conclusion: Preoperative blood glucose monitoring is recommended mandatorily for all patients posted for emergency surgery. It is also recommended for elective pediatric and geriatric surgery patients, patients with high anxiety and/or pain, increased NPO duration, and preoperative administration of steroid, NS, 6% HES, or blood.

Keywords: Age, Anxiety, Blood glucose, Blood sugar, Intravenous fluids, Nil by mouth, Nil per os, Nondiabetic, Pain, Preoperative, Steroids.

How to cite this article: Pattajoshi S, Nerurkar AA, Tendolkar BA. A Cross-sectional Observational Analysis of Preoperative Blood Glucose Levels in Nondiabetic Patients presenting for Surgery. Res Inno in Anesth 2017;2(2):29-33.

Source of support: Nil

Conflict of interest: None


ORIGINAL RESEARCH
Aarti Kulkarni, Paulomi Dey

Comparison between Clinical Efficacies of Levobupivacaine Plain and Levobupivacaine with Fentanyl for Urological Surgeries under Subarachnoid Block

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:34-39]



Background and aims: Spinal anesthesia for urological operations has been frequently used, because symptoms of overhydration, transurethral resection of prostate (TURP) syndrome, and bladder perforation can be recognized. This prospective randomized study was conducted to compare the clinical efficacies of levobupivacaine with and without fentanyl in subarachnoid block with respect to onset and duration of sensory and motor block and duration of analgesia in urological surgeries.

Materials and methods: This randomized study was conducted in 100 patients of American Society of Anesthesiologists (ASA) physical status grades I and II, posted for urological surgeries. Patients were randomly allocated to two groups and were given the following drugs intrathecally as per group distribution: Group I: 2.5 mL of 0.5% isobaric levobupivacaine and group II: 2.2 mL of 0.5% isobaric levobupivacaine with 15 μg (0.3 mL) fentanyl citrate. Parameters monitored were onset and duration of sensory and motor block, hemodynamic parameters, postoperative analgesia, and side effects. Data were analyzed using Student’s t-test for the continuous variables and chi-square test for categorical variables.

Results: The onset of sensory level of T10 was earlier in group II (4.74 ± 0.723 minutes) than in group I (5.7 ± 0.953 minutes). Duration of sensory block was longer in group I (292.2 ± 8.154 minutes) than in group II (260 ± 11.066 minutes). Motor block regressed earlier in group II (181.2 ± 7.73 minutes) than in group I. Hemodynamic parameters and side effects were similar in both the groups.

Conclusion: From our study, we concluded that plain levobupivacaine provided a longer duration of sensory and motor subarachnoid blockade. However, addition of fentanyl as a spinal adjuvant had a dose-sparing effect with earlier onset and early regression of motor block and no hemodynamic alterations.

Keywords: Intrathecal fentanyl, Levobupivacaine, Spinal adjuvant, Transurethral resection of prostate, Urology.

How to cite this article: Kulkarni A, Dey P. Comparison between Clinical Efficacies of Levobupivacaine Plain and Levobupivacaine with Fentanyl for Urological Surgeries under Subarachnoid Block. Res Inno in Anesth 2017;2(2):34-39.

Source of support: Nil

Conflict of interest: None


ORIGINAL RESEARCH
Ketan S Kulkarni, Nandini M Dave, Shriyam S Kulkarni, Gita Nataraj, Shivani Shinde, Indrani Chincholi, Madhu Garasia

A Prospective, Randomized Study comparing the Efficacy and Safety of Adhesive Strip (Steri-Strips™) Fixation vs Subcutaneous Tunneling for securing Epidural Catheters in Pediatric Patients

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:40-44]



Introduction: Effective epidural catheter fixation is a key aspect of postoperative pain management in pediatric patients. We conducted a prospective, randomized study comparing the efficacy and safety of adhesive strip (Steri-Strips™) vs subcutaneous tunneling for successful epidural catheter fixation.

Materials and methods: American Society of Anesthesiologists (ASA) grades I and II patients between the age group of 1 day and 12 years were included in the study. The parameters studied were inward and outward migration, and dislodgment of catheter. Erythema, induration, catheter snapping, catheter obstruction, total duration of epidural infusion, and catheter tip culture were also recorded. Feedback from the operator for ease of fixation technique was noted and reviewed.

Results: This study was performed in 64 patients posted for various abdominal, thoracic, and genital surgeries, requiring postoperative epidural analgesia. The epidural catheter was successfully placed in the first attempt in 61 patients. Outward migration was seen in six patients with Steri-Strips-taped catheters and in one patient with a tunneled catheter. Accidental removal was done in five patients with tunneled catheters and one patient with strip-taped catheter. Rescue analgesics were required in these patients. No inward migration of catheter was seen in both the groups. Bleeding from tunneling site was seen in five patients.

Conclusion: In comparison with a tunneling technique for epidural catheter fixation, a simple method of applying Steri- Strips™ to epidural catheters significantly reduces the incidence of accidental removal.

Keywords: Epidural catheter fixation, Pediatric patients, Steri- Strip, Subcutaneous tunneling.

How to cite this article: Kulkarni KS, Dave NM, Kulkarni SS, Nataraj G, Shinde S, Chincholi I, Garasia M. A Prospective, Randomized Study comparing the Efficacy and Safety of Adhesive Strip (Steri-Strips™) Fixation vs Subcutaneous Tunneling for securing Epidural Catheters in Pediatric Patients. Res Inno in Anesth 2017;2(2):40-44.

Source of support: Nil

Conflict of interest: None


ORIGINAL RESEARCH
Pragya Sachan, Naina P Dalvi

Monitoring of Depth of Anesthesia using Entropy Monitor during Cardiopulmonary Bypass

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:45-50]



Aim: To monitor the depth of anesthesia using entropy monitor during cardiopulmonary bypass (CPB) using (1) numerical indices provided by entropy monitor [response entropy (RE) and state entropy (SE), burst suppression ratio (BSR)] and (2) modified version of Brice questionnaire used after 48 hours of surgery.

Materials and methods: Design: Prospective observational study. Setting: Cardiovascular thoracic surgery (CVTS) operation theater (OT) of our hospital. Participants: 100 patients undergoing CPB surgery and willing to participate in the study. Intervention: Brain and facial muscular activity recorded using disposable sensor with three electrodes attached to patient’s forehead and a sensor cable that connects the sensor to entropy module. Entropy indices were calculated and displayed in real time. All patients were then interviewed 48 hours after surgery about any recall of intraoperative awareness using the modified Brice questionnaire.

Measurements and results: Basic statistics was assessed by using MS Excel Office 2007 data analysis Tool Pack. The association between two variables was determined by Pearson chi-square test. After skin incision, mean RT and ST were found to decrease significantly till peak hypothermia. After start of rewarming, mean RT and ST were found to increase significantly till skin closure.

Conclusion: In our study, we did not find any awareness in all 100 studied subjects, leading to the conclusion that anesthesia technique used for CPB is optimal.

Clinical significance: It can be concluded that entropy monitor might aid CPB surgery in many ways. It monitors the depth of anesthesia and probably prevents intraoperative awareness, helps in reducing anesthetic dosage, and hence, reduction in cost of anesthesia.

Keywords: Cardiopulmonary bypass, Depth of anesthesia, Electroencephalogram-based monitors, Entropy, Monitoring.

How to cite this article: Sachan P, Dalvi NP. Monitoring of Depth of Anesthesia using Entropy Monitor during Cardiopulmonary Bypass. Res Inno in Anesth 2017;2(2):45-50.

Source of support: Nil

Conflict of interest: None


ORIGINAL RESEARCH
Meenoti P Potdar, Ajay Tomar, Laxmi Kamat

Comparison of Ropivacaine with Fentanyl vs Bupivacaine with Fentanyl for Postoperative Epidural Analgesia in Total Knee Arthroplasty: A Prospective Randomized, Single-blinded Controlled Study

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:51-57]



Aim: The primary aim of the study was to compare epidural ropivacaine with fentanyl and epidural bupivacaine with fentanyl for postoperative epidural analgesia after total knee arthroplasty (TKA). The secondary objective was to assess the outcomes of passive and active mobilizations postoperatively, requirement of rescue analgesia, and adverse effects, such as nausea vomiting, sedation, numbness, motor weakness, hypotension, and respiratory depression.

Materials and methods: After obtaining hospital ethics committee approval and written informed consent, 100 patients were randomly allocated to two groups of 50 each. Group B received 0.125% bupivacaine with fentanyl (2 μg/mL) epidurally for postoperative pain relief. Group R received 0.2% ropivacaine with fentanyl (2 μg/mL) epidurally for postoperative pain relief. Patients of American Society of Anesthesiologists (ASA) grades I to II of both sexes undergoing elective TKA and giving written consent were included in the study. Patients with coagulation disorders, history of spine surgery, vertebral deformities, and having contraindications for spinal analgesia were excluded from the study. All patients were preoperatively assessed and clinically evaluated thoroughly. They received conventional combined spinal epidural anesthesia followed by epidural infusion in the postoperative period of ropivacaine fentanyl or bupivacaine fentanyl as per the allocation. The postoperative epidural analgesia was supplemented with intravenous (IV) paracetamol 1 gm TDS, and rescue analgesia, if needed, was given with IV tramadol 50 mg. All patients were monitored for postoperative pain by the visual analog scale (VAS), requirement of rescue analgesia, hemodynamic parameters, sedation scores, and adverse effects.

Keywords: Bupivacaine, Epidural, Fentanyl, Ropivacaine, Total knee arthroplasty.

How to cite this article: Potdar MP, Tomar A, Kamat L. Comparison of Ropivacaine with Fentanyl vs Bupivacaine with Fentanyl for Postoperative Epidural Analgesia in Total Knee Arthroplasty: A Prospective, Randomized, Single-blinded Controlled Study. Res Inno in Anesth 2017;2(2):51-57.

Source of support: Nil

Conflict of interest: None


ORIGINAL RESEARCH
Indrani H Chincholi, Harprit K Madan, Sonali D Patira

Pain Perception following Administration of Propofol with 7.5 mg Ephedrine, 15 mg Ephedrine, or Lignocaine: A Comparative Study

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:58-63]



Introduction: Propofol is the drug of choice for induction of anesthesia because of its rapid onset, easy titration, and short duration of action. However, pain on propofol injection is an unpleasant experience felt by many of our patients. Many factors have been investigated to decrease the pain on propofol injection but it is still a mystery.

Aim: To compare the effect of two doses of ephedrine (7.5 and 15 mg) and lignocaine on pain during injection of propofol and to compare their hemodynamic parameters and note for any complications.

Materials and methods: This study was a prospective, randomized, double-blinded, single-center study on 150 adult patients of both the sexes belonging to American Society of Anesthesiologists (ASA) grades I and II for elective surgery under general anesthesia. The aim was to compare the analgesic effect of lignocaine, ephedrine 7.5 and 15 mg in ameliorating propofol injection pain. About 50 patients were allocated to each of the three groups receiving lignocaine 2% (1.5 mL), ephedrine 7.5 mg, and ephedrine 15 mg intravenously admixed with propofol. The intensity of pain at the time of propofol injection was assessed using verbal rating scale (VRS) 4-point scale before the patient lost consciousness.

Statistical analysis: Statistical analysis was done by using Statistical Package for the Social Sciences (SPSS) version 22.0 software. The qualitative data were summarized as frequency and percentages. The Fischer exact test was used to analyze the data. The continuous data were summarized as mean and standard deviation. The group and intergroup analyses were done using repeated measures analysis of variance (ANOVA) test. A p-value <0.05 was considered significant.

Results: Median (interquartile range) of the pain score was 1 (2) in group E-7.5 mg, 0 (1) in group E-15 mg, and 0(1) in group L. Results were statistically significant.

Conclusion: Adding 15 mg ephedrine was as effective as adding lignocaine for the prevention of propofol injection pain and ephedrine had a better and stable hemodynamic profile.

Keywords: Ephedrine, Pain, Propofol.

How to cite this article: Chincholi IH, Madan HK, Patira SD. Pain Perception following Administration of Propofol with 7.5 mg Ephedrine, 15 mg Ephedrine, or Lignocaine—A Comparative Study. Res Inno in Anesth 2017;2(2):58-63.

Source of support: Nil

Conflict of interest: None


ORIGINAL RESEARCH
Apeksha A Gala, Pritee H Bhirud, Shrividya Chellam

Intravenous Dexamethasone and Its Effect on Blood Glucose in Adult Nondiabetic Patients undergoing General Anesthesia for Superficial Surgery

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:64-67]



Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV). It also has significant postoperative analgesic benefits. In spite of these advantages, it is seen that intravenous (IV) dexamethasone may affect the blood glucose profile of the patient and healing of wounds. We have studied the effects of IV dexamethasone administered at induction on blood glucose concentrations in adult, nondiabetic patients under general anesthesia (GA) for superficial surgeries, e.g., ear surgeries, breast surgeries, and hernia surgeries.

Keywords: Blood glucose concentration, Intravenous dexamethasone, Nondiabetic adult patients, Superficial surgery.

How to cite this article: Gala AA, Bhirud PH, Chellam S. Intravenous Dexamethasone and Its Effect on Blood Glucose in Adult Nondiabetic Patients undergoing General Anesthesia for Superficial Surgery. Res Inno in Anesth 2017;2(2):64-67.

Source of support: Nil

Conflict of interest: Nil


CASE REPORT
Apeksha A Gala, Naina P Dalvi, Sunil K Gvalani, Sourav Mahajan

A Case of suspected Sick Sinus Syndrome due to combined Beta-blocker and Calcium Channel Blocker Therapy: Anesthesia Management

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:68-70]



Sick sinus syndrome (SSS) is a generalized abnormality of cardiac impulse formation. Abnormalities encompassed by this syndrome may include inappropriate sinus bradycardia, sinus arrest, bradyarrhythmias, or tachyarrhythmias. We present a case of a 54-year-old hypertensive male posted for L4-L5 decompression, whom we suspected to develop SSS due to overdose of combined beta-blocker (BB) and calcium channel blocker (CCB) therapy.

Keywords: Beta-blocker-calcium channel blocker toxicity, Inotropes, Preanesthesia checkup, Sick sinus syndrome.

How to cite this article: Gala AA, Dalvi NP, Gvalani SK, Mahajan S. A Case of suspected Sick Sinus Syndrome due to combined Beta-blocker and Calcium Channel Blocker Therapy: Anesthesia Management. Res Inno in Anesth 2017;2(2):68-70.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Tanya R Jha, Meenoti P Potdar

Knotted Ryle’s Tube: A Rare Complication

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:71-72]



Ryle’s tube (RT) insertion is a commonly performed procedure in emergency departments, intensive care units, and operation theaters. The complications associated with RT include ulceration, bleeding, misplacement of the tube in airway, and clogging of the tube. Intragastric knotting is a rare complication of RT insertion. The removal of such knotted RT should be done cautiously so as to avoid trauma, preferably under direct laryngoscopic vision.

Keywords: Intragastric tube, Knotted, Ryle’s tube.

How to cite this article: Jha TR, Potdar MP. Knotted Ryle’s Tube: A Rare Complication. Res Inno in Anesth 2017;2(2):71-72.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Harsha Narkhede, Shrikanta P Oak, Isha Singhal, Neha Apte, Monal Shah

Anesthetic Management of Emergency Cesarean Section in a Patient with Congenital Venous Malformation.

[Year:2017] [Month:July-December] [Volumn:2 ] [Number:2] [Pages:46] [Pages No:73-75]



Blue rubber bleb nevus syndrome (BRBNS) is characterized by typical bluish, soft, and compressible lesions with rubber-like consistency present since birth. In this syndrome, venous malformation (VM) is always present since birth and is commonly found in the cheek, tongue, lip and jaw, and sometimes may be present in deep tissue, bone, or muscle. A vascular malformation is known to grow in size throughout the life of an individual with sudden enlargement in size during puberty and pregnancy due to hormonal changes. We report the successful management of a case of congenital VM of the lip and mandible posted for emergency cesarean section under spinal anesthesia.

Keywords: Blue rubber bleb nevus syndrome, Cesarean section, Congenital venous malformation, Pregnancy, Spinal anesthesia.

How to cite this article: Narkhede H, Oak SP, Singhal I, Apte N, Shah M. Anesthetic Management of Emergency Cesarean Section in a Patient with Congenital Venous Malformation. Res Inno in Anesth 2017;2(2):73-75.

Source of support: Nil

Conflict of interest: None


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