Background and Aims:
Modified Radical Mastectomy (MRM) is the commonly used surgical procedure for operable breast cancer, which involves extensive tissue dissection. Therefore, wound instillation with local anaesthetic may provide better postoperative analgesia than infiltration along the line of incision. We hypothesised that instillation of bupivacaine through chest and axillary drains into the wound may provide postoperative analgesia.
In this prospective randomised controlled study 60 patients aged 45–60 years were divided into three groups. All patients were administered general anaesthesia. At the end of the surgical procedure, axillary and chest wall drains were placed before closure. Group C was the control with no instillation; Group S received 40 ml normal saline, 20 ml through each drain; and Group B received 40 ml of 0.25% bupivacaine and the drains were clamped for 10 min. After extubation, pain score for both static and dynamic pain was evaluated using visual analog scale and then 4th hourly till 24 h. Rescue analgesia was injection tramadol, if the pain score exceeds 4. Statistical analysis was performed using SPSS version 13.
There was a significant difference in the cumulative analgesic requirement and the number of analgesic demands between the groups (P: 0.000). The mean duration of analgesia in the bupivacaine group was 14.6 h, 10.3 in the saline group and 4.3 h in the control group.
Wound instillation with local anaesthetics is a simple and effective means of providing good analgesia without any major side-effects.
Local anaesthetic; mastectomy; postoperative pain; wound instillation
Background and Aims:
Continuous arterial pressure monitoring is essential in cardiac surgical patients during induction of general anaesthesia (GA). Continuous non-invasive arterial pressure (CNAP) monitoring is fast gaining importance due to complications associated with the invasive arterial monitoring. Recently, a new continuous non-invasive arterial pressure device (CNAP™) has been validated perioperatively in non-cardiac surgeries. The aim of our study is to compare and assess the performance of CNAP during GA with invasive arterial pressure (IAP) in patients undergoing cardiac surgeries.
Sixty patients undergoing cardiac surgery were included. Systolic, diastolic, and mean arterial pressure (MAP) data were recorded every minute for 20 min simultaneously for both IAP and CNAP™. Statistical analysis was performed using mountain plot and Bland Altman plots for assessing limits of agreement and bias (accuracy) calculation. Totally 1200 pairs of data were analysed.
The CNAP™ systolic, diastolic and MAP bias was 5.98 mm Hg, −3.72 mm Hg, and − 0.02 mm Hg respectively. Percentage within limits of agreement was 96.0%, 95.2% and 95.7% for systolic, diastolic and MAP. The mountain plot showed similar results as the Bland Altman plots.
We conclude CNAP™ provides real-time estimates of arterial pressure comparable to IAP during induction of GA for cardiac surgery. We recommend CNAP can be used as an alternative to IAP in situations such as cardiac patients coming for non-cardiac surgeries, cardiac catheterization procedures, positive Allen's test, inability to cannulate radial artery and vascular diseases, where continuous blood pressure monitoring is required.
Continuous non-invasive arterial pressure; general anaesthesia; invasive arterial pressure
Background and Aims:
Middle ear surgery requires bloodless surgical field for better operating conditions, deep level of anaesthesia and rapid emergence. Recent studies suggest that α2 agonists could provide desired surgical field, sedation and analgesia. The present study was aimed to evaluate the clinical effects of dexmedetomidine infusion as anaesthetic adjuvant during middle ear surgery using operating microscope.
Sixty four adult patients aged 18-58 years, American Society of Anaesthesiologists Grades I and II, of both gender were randomised into two comparable equal groups of 32 patients each for middle ear surgery under general anaesthesia with standard anaesthetic technique. After induction of general anaesthesia, patients of Group I were given dexmedetomidine infusion of 0.5 μg/kg/h and patients of Group II were given placebo infusion of normal saline. Isoflurane concentration was titrated to achieve a systolic blood pressure 30% below the baseline value. All patients were assessed intra-operatively for bleeding at surgical field, haemodynamic changes, awakening time and post-operative recovery.
Statistically significant reduction was observed in the required percentage of isoflurane (0.8 ± 0.6%) to maintain the systolic blood pressure 30% below the baseline values in patients receiving dexmedetomidine infusion when compared to those receiving placebo infusion (1.6 ± 0.7%). Patients receiving dexmedetomidine infusion had statistically significant lesser bleeding at surgical field (P < 0.05). The mean awakening time and recovery from anaesthesia did not show any significant difference between the groups.
Dexmedetomidine infusion can be safely used to provide oligaemic surgical field for better visualization using operating microscope for middle ear surgery.
Dexmedetomidine; middle ear surgery; oligaemic surgical field
Background and Aims:
Cardiac arrest has multifactorial aetiology and the outcome depends on timely and correct interventions. We decided to investigate the circumstances, incidence and outcome of cardiopulmonary resuscitation (CPR) at a tertiary hospital in India, in relation to various factors, including extensive basic life support and advanced cardiac life support training programme for all nurses and doctors.
It has been over a decade and a half with periodical updates and implementation of newer guidelines prepared by various societies across the world about CPR for both in-hospital and out-of hospital cardiac arrests (IHCA and OHCA). We conducted a prospective study wherein all cardiac arrests reported in the hospital consecutively for 12 months were registered for the study and followed their survival up to 1-year. Statistical analysis was performed by using Chi-square test for significant differences in proportions applied to various parameters of the study.
The main outcome measures were; (following CPR) return of spontaneous circulation, survival for 24 h, survival from 24 h to 6 weeks or discharge, alive at 1-year. For survivors, an assessment was made about their cerebral performance and overall performance and accordingly graded. All these data were tabulated. Totally 419 arrests were reported in the hospital, out of which 413 were in-hospital arrests. Out of this 260 patients were considered for resuscitation, we had about 27 survivors at the end of 1-year follow-up (10.38%).
We conclude by saying there are many factors involved in good clinical outcomes following IHCAs and these variable factors need to be researched further.
Cardiac arrest; Cardiopulmonary resuscitation(CPR); outcome; tertiary hospital
Background and Aims:
Post-operative sore throat (POST) occurs in 21-65% of patients. Ketamine used earlier as gargle for reducing POST has limitations. The aim of this study was to see if nebulised ketamine reduces POST.
We conducted a prospective, randomised, placebo-control, and double-blind controlled trial. After written informed consent, 100 patients belonging to American Society of Anaesthesiologists physical status I-II in the age group 20-60 years, of either sex undergoing surgery under general anaesthesia (GA) were enrolled. Patients were randomised into two groups; group saline (S) received saline nebulisation 5.0 ml and group ketamine (K) received ketamine 50 mg (1.0 ml) with 4.0 ml of saline nebulisation for 15 min. GA was induced 10 min after completion of nebulisation in the patients. The POST and haemodynamic monitoring were done pre-nebulization, pre-induction, on reaching post-anaesthesia care unit, and at 2, 4, 6, 8, 12 and 24 h post-operatively. POST was graded on a four-point scale (0-3).
The overall incidence of POST was 33%; 23 patients (46%) in saline and 10 patients (20%) in ketamine group experienced POST (Fisher's exact P = 0.01). The use of ketamine nebulization attenuated POST at 2 h and 4 h post-operatively (P < 0.05). The primary outcome was incidence of POST at 4 h; 13 patients in group S versus 4 patients in group K (P = 0.03) experienced POST at 4 h. The moderate sore throat occurred in 6 patients in group S and none in group K at 2 h, post-operatively (P = 0.02).
Ketamine nebulization significantly attenuated the incidence and severity of POST, especially in the early post-operative period, with no adverse effects.
Ketamine; nebulization; post-operative sore throat; tracheal intubation
Panthothenate kinase-associated neurodegeneration (PKAN) (Hallervorden-Spatz disease) is a rare autosomal recessive chromosomal disorder characterised by progressive neuroaxonal dystrophy. The characteristic features include involuntary movements, rigidity, mental retardation, seizures, emaciation. The anaesthetic concerns include difficult airway, aspiration pneumonia, dehydration, and post-operative respiratory, and renal insufficiency. We report successful anaesthetic management of a 9-year-old intellectually disabled male child with PKAN, scheduled for ophthalmic surgery under general anaesthesia.
Aspiration pneumonia; difficult airway; dystonia; muscle spasm; panthothenate kinase-associated neurodegeneration; respiratory failure
Transfluthrin is being used as fast acting insecticide and liquid mosquito repellent. This is a case report of poisoning with transfluthrin (90 ml liquid containing 792 mg of transfluthrin) by a 25-year-old female. Tonic-clonic convulsions were not controlled with conventional drugs. In intensive care unit, patient was managed with muscle paralysis by neuromuscular blocking drug vecuronium and elective mechanical ventilation for more than 48 h under care of the anaesthesiologist with uneventful recovery.
Elective ventilation; seizures; transfluthrin
Targeted temperature management (TTM) for neuroprotection involves maintaining the temperature of the brain at predetermined levels by various techniques. It is aimed at avoiding the harmful effects of hyperthermia on the brain and at exploiting the protective effects of lower tissue temperature. There has been an explosion in the use of TTM for neuroprotection in a variety of clinical scenarios apart from the commonly accepted fields of resuscitation and ischaemic, hypoxic encephalopathy. This review briefly discusses the evidence base for TTM. The focus is on various areas of application for neuroprotection, the practical issues pertaining to TTM implementation, the recent data that support it and the present areas of controversy.
Endovascular cooling; hypothermia; neuroprotection; targeted temperature management; therapeutic temperature management
Blood transfusion is an essential component of emergency obstetric care and appropriate blood transfusion significantly reduces maternal mortality. Obstetric haemorrhage, especially postpartum haemorrhage, remains one of the major causes of massive haemorrhage and a prime cause of maternal mortality. Blood loss and assessment of its correct requirement are difficult in pregnancy due to physiological changes and comorbid conditions. Many guidelines have been used to assess the requirement and transfusion of blood and its components. Infrastructural, economic, social and religious constraints in blood banking and donation are key issues to formulate practice guidelines. Available current guidelines for transfusion are mostly from the developed world; however, they can be used by developing countries keeping available resources in perspective.
Obstetric anaesthesia; obstetric haemorrhage; postpartum haemorrhage; transfusion practices; transfusion protocol
Coagulation is a dynamic process and the understanding of the blood coagulation system has evolved over the recent years in anaesthetic practice. Although the traditional classification of the coagulation system into extrinsic and intrinsic pathway is still valid, the newer insights into coagulation provide more authentic description of the same. Normal coagulation pathway represents a balance between the pro coagulant pathway that is responsible for clot formation and the mechanisms that inhibit the same beyond the injury site. Imbalance of the coagulation system may occur in the perioperative period or during critical illness, which may be secondary to numerous factors leading to a tendency of either thrombosis or bleeding. A systematic search of literature on PubMed with MeSH terms ‘coagulation system, haemostasis and anaesthesia revealed twenty eight related clinical trials and review articles in last 10 years. Since the balance of the coagulation system may tilt towards bleeding and thrombosis in many situations, it is mandatory for the clinicians to understand physiologic basis of haemostasis in order to diagnose and manage the abnormalities of the coagulation process and to interpret the diagnostic tests done for the same.
Anaesthesia; Coagulation system; haemostasis
International Society of Blood Transfusion has recently recognized 33 blood group systems. Apart from ABO and Rhesus system, many other types of antigens have been noticed on the red cell membranes. Blood grouping and cross-matching is one of the few important tests that the anaesthesiologist orders during perioperative period. Hence, a proper understanding of the blood group system, their clinical significance, typing and cross-matching tests, and current perspective are of paramount importance to prevent transfusion-related complications. Nonetheless, the knowledge on blood group system is necessary to approach blood group-linked diseases which are still at the stage of research. This review addresses all these aspects of the blood groups system.
ABO blood groups; antibody typing; blood group system; rhesus blood group; screening
The whole blood which is a mixture of cells, colloids and crystalloids can be separated into different blood components namely packed red blood cell (PRBC) concentrate, platelet concentrate, fresh frozen plasma and cryoprecipitate. Each blood component is used for a different indication; thus the component separation has maximized the utility of one whole blood unit. Different components need different storage conditions and temperature requirements for therapeutic efficacy. A variety of equipments to maintain suitable ambient conditions during storage and transportation are in vogue. The blood components being foreign to a patient may produce adverse effects that may range from mild allergic manifestations to fatal reactions. Such reactions are usually caused by plasma proteins, leucocytes, red cell antigens, plasma and other pathogens. To avoid and reduce such complications, blood products are modified as leukoreduced products, irradiated products, volume reduced products, saline washed products and pathogen inactivated products. The maintenance of blood inventory forms a major concern of blood banking particularly of rare blood groups routinely and common blood groups during disasters. PRBCs can be stored for years using cryopreservation techniques. New researches in red cell cultures and blood substitutes herald new era in blood banking.
Blood; blood component transfusion; blood components; erythrocyte transfusion; fresh frozen plasma; leukocyte transfusion; lymphocyte transfusion; platelet concentrate; platelet transfusion; red cell concentrate