The prognostic value of microRNA-375 (miR-375) expression in squamous cell carcinoma (SCC) had been reported in the previous studies; however, the results remain inconsistent. This study was performed to investigate the prognostic significance of miR-375 expression in SCC based on all eligible evidences.
Methods
Relevant studies were identified by searching PubMed, Embace, Medline, Cochrane Library, and China Biology Medicine disk. Survival outcome including overall survival (OS) and other survival outcomes were used as the primary endpoint to evaluate the prognostic outcome of patients with SCC. All statistical analyses were performed in RevMan software version 5.3 and STATA software version 14.1. Furthermore, the quality of included studies was assessed by The Newcastle–Ottawa Scale.
Results
In total, 13 studies, including 1340 patients, met the inclusion criteria for our meta-analysis. The pooled analysis results indicated that downregulation of miR-375 significantly predicted poor OS (HR 1.58, 95% CI 1.34–1.88, P < 0.001). Downregulated miR-375 was also correlated with the other survival outcomes. Subgroup analysis based on tumor type found that lower expression of miR-375 was significantly related with poor OS in patients with esophageal squamous cell carcinoma (ESCC) (HR 1.58, 95% CI 1.29–1.94, P < 0.001) and head and neck squamous cell carcinoma (HNSCC) (HR 1.59, 95% CI 1.16–2.18, P = 0.004).
Conclusions
This meta-analysis demonstrated that the downexpression of miR-375 was significantly correlated with poor OS in patients with SCCs and indicated the potential clinical use of miR-375 as a molecular biomarker, particularly in assessing prognosis for patients with ESCC and HNSCC.
The effects of propofol and isoflurane on intraoperative motor evoked potentials during spinal cord tumour removal surgery - A prospective randomised trialp. 92
Parthiban Velayutham, Verghese T Cherian, Vedantam Rajshekhar, Krothapalli S Babu
DOI:10.4103/ija.IJA_421_18
Background and Aims: Transcranial electrical stimulation (TES) elicited intraoperative motor evoked potentials (iMEPs), are suppressed by most anaesthetic agents. This prospective randomised study was carried out to compare the effects of Isoflurane and Propofol on iMEPs during surgery for spinal cord tumours. Methods: A total of 110 patients were randomly divided into two groups. In group P, anaesthesia was maintained with intravenous propofol (6.6 ± 1.5 mg/kg/hr) and in group I anaesthesia was maintained with isoflurane (0.8 ± 0.1% minimal alveolar concentration (MAC). An Oxygen- air mixture (FiO2-0.3) was used in both groups. TES-iMEPs were recorded from tibialis anterior, quadriceps, soleus and external anal sphincter muscles in 60 of 90 patients. Statistical analysis was performed with Pearson correlation and Paired 't' tests. Results: Successful baseline iMEPs were recorded in 74% of patients in Group P and in 50% of patients in Group I. Age and duration of symptoms influenced the elicitation of baseline iMEPs under isoflurane (r = −0.71, −0.66 respectively, P < 0.01) as compared to propofol (r = −0.60, −0.50 respectively, P < 0.01). The mean stimulus strength required to elicit the baseline iMEPs were lesser in propofol (205 ± 55Volts) as compared to isoflurane (274 ± 60 Volts). Suppression of the iMEP responses was less under propofol (7.3%) as compared to isoflurane anaesthesia (11.3%) in patients with no preoperative neurological deficits. Conclusion: iMEPs are better maintained under propofol anaesthesia (6-8 mg/kg/hr) when compared with isoflurane (0.7-0.9 MAC). in patients undergoing surgery for excision of spinal cord tumours.
Background and Aims: Direct laryngoscopy and tracheal intubation is a noxious stimulation that induces significant stress response. Currently, this nociceptive response is assessed mainly by haemodynamic changes. Recently, analgesia nociception index (ANI) is introduced into anaesthesia practice and provides objective information about parasympathetic (low nociceptive stress) and sympathetic (high nociceptive stress) balance, which reflects the degree of intraoperative nociception/analgesia. This study evaluated the changes in ANI and haemodynamics during anaesthetic induction and intubation, and their correlation during tracheal intubation. Methods: Sixty adult patients scheduled for elective brain tumour surgery under general anaesthesia were studied for changes in ANI, heart rate (HR) and mean blood pressure (MBP) during anaesthetic induction and intubation. This was a secondary analysis of a previously published trial. Linear mixed effects model was used to evaluate changes in ANI, HR and MBP and to test correlation between ANI and haemodynamics. Results: Anaesthetic induction reduced ANI (but not below the critical threshold of nociception of 50) and MBP, and increased the HR (P < 0.001). Direct laryngoscopy and tracheal intubation resulted in increase in HR and MBP with decrease in ANI below the threshold of 50 (P < 0.001). A linear negative correlation was observed between ANI and HR; r = −0.405, P < 0.001, and ANI and MBP; r = −0.415, P= 0.001. Conclusion: Significant changes are observed in ANI during anaesthetic induction and intubation. There is a negative linear correlation between ANI and systemic haemodynamics during intubation.
Correspondence Address: Dr. Shalendra Singh Department of Anaesthesiologist and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra India
Source of Support: None, Conflict of Interest: None
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DOI: 10.4103/ija.IJA_573_18
How to cite this article: Saurav, Singh S, Kiran S, Jaiswal A. Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis. Indian J Anaesth 2019;63:148-50
How to cite this URL: Saurav, Singh S, Kiran S, Jaiswal A. Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 12];63:148-50. Available from: http://www.ijaweb.org/text.asp?2019/63/2/148/251972
Sir,
It is not very common to manage a patient with ankylosing spondylitis (AS) and bilateral 'temporomandibular joint' (TMJ) ankylosis with cervical spine fusion to undergo alloplastic joint replacement. However, anaesthetic management of such patients in the context of difficult airway has been described.[1] AS presents challenges to the anaesthesiologist as a consequence of potential difficult airway, cardiovascular, respiratory complications and increased risk of neurological complications. Incidence of TMJ involvement is 4–24% in AS; however, a case where bilateral TMJ ankylosis associated with cervical spine fusion and AS having undergone total alloplastic joint replacement is rare.
A 39-year-old male patient with complaint of difficulty in mouth opening for the past 18 years presented for bilateral alloplastic TMJ replacement. Airway examination revealed 6 mm of interincisor distance, grade IV Mallampati score with no lateral movement of the mandible, along with rigidity of cervical spine. Computerised tomography scan of both TMJs confirmed severe ankylosis [Figure 1]. X-ray of the cervical spine revealed fusion of the cervical spine [Figure 2]. All routine investigations including haemogram, biochemistry, chest X-ray and ECG were within normal limits. No abnormality was detected in lung function tests and arterial blood gas analysis.
He was planned for general anaesthesia with awake fibreoptic nasal intubation which is the gold standard[2] in view of restricted mouth opening and potential loss of airway under muscle relaxant. In the operation theatre, trolley for emergency surgical tracheostomy was kept ready. All standard monitoring devices were attached and the patient was pre-medicated with inj. glycopyrrolate 0.2 mg intravenous (IV) and inj. midazolam 1 mg IV. For nasal decongestion and topical anaesthesia, xylometazoline 0.05% nasal drops (3–5 drops) were instilled and nasal packing by gauze soaked in 2% lignocaine was done. Recurrent laryngeal nerve block was performed by injecting 2 ml of 4% lignocaine after piercing the cricothyroid membrane. Mild sedation for the awake fibreoptic intubation was achieved with inj. dexmedetomidine 20 μg IV and inj. ketamine 20 mg IV. After pre-oxygenation, both nasal passages were lubricated with lubricant jelly and fibreoptic bronchoscope was passed through the left nasal passage. After manipulation, epiglottis was visualised, and with spray-as-you-go technique using 4% topical lignocaine glottis was visualised. The pre-loaded flexo-metallic cuffed endotracheal tube size 7.0 mm was gently advanced over the bronchoscope. The position of the tube was confirmed by ETCO2 and the anaesthesia was induced with inj. propofol 120 mg IV and maintained on O2, N2O, isoflurane and vecuronium. Intraoperative period was uneventful. Operating on each side of his face posed a practical problem because of the rigidity of his cervical spine, which required a bodily tilt of the operating table by 15–25° on each side. Neck support was used during anaesthesia and movements of the neck in the presence of neuromuscular blockade were restricted to avoid neurological injury. Three litres of crystalloid were infused intraoperatively with a total blood loss of 350 ml. The patient was shifted to surgical intensive care unit (SICU) with endotracheal tube in situ and maintained on assisted ventilation support in view of difficult airway and risk of airway oedema. After 12 h, the trachea was extubated uneventfully in SICU over an airway exchange catheter in view of potential difficult extubation. The same precautions regarding patient positioning and neck movement were applied at emergence, as with intubation. The patient was discharged on the seventh postoperative day.
To conclude, we successfully managed a case of AS with bilateral TMJ ankylosis having cervical spine fusion undergoing alloplastic joint replacement. It is emphasised that the prime concerns of the anaesthesiologists are to maintain a patent airway and maintain immobility of cervical spine, apart from the other anaesthetic concerns during perioperative management of such patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Dave N, Sharma RK. Temporomandibular joint ankylosis in a case of ankylosing spondylitis – Anaesthetic management. Indian J Anaesth 2004;48:54-6. [Full text]
Correspondence Address: Dr. Saurabh Sud Department of Anesthesia and Critical Care, Command Hospital (Southern Command) Armed Forces Medical College, Pune - 411 040, Maharashtra India
Source of Support: None, Conflict of Interest: None
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DOI: 10.4103/ija.IJA_623_18
How to cite this article: Dwivedi D, Sud S, Sawhney S, Panjiyar SP. Unseen complication of the exhausted soda lime. Indian J Anaesth 2019;63:150-1
How to cite this URL: Dwivedi D, Sud S, Sawhney S, Panjiyar SP. Unseen complication of the exhausted soda lime. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 12];63:150-1. Available from: http://www.ijaweb.org/text.asp?2019/63/2/150/251974
Sir,
During general anaesthesia an average adult produces 10–12 l of carbon dioxide per hour. Ralph Waters in 1923 pioneered the use of soda lime for chemically absorbing carbon dioxide.[1] Approximately 100 g of soda lime absorbs around 26 l of carbon dioxide.[2] Soda lime by removing carbon dioxide from fresh gas flow helps in recirculating the unused gases back into the circle system. This helps in economically reducing the requirement of fresh gas flow (oxygen, nitrous, and inhalation agents), and thus decreases pollution in operation theatre. We present here reporting of an unusual incident of an excessive water collection in the soda lime canister assembly at the anaesthesia workstation.
A 56-year-old lady was administered general anaesthesia with continuous epidural analgesia for total abdominal hysterectomy. After 25 min into surgery, monitoring showed increased peak airway pressure from the baseline of 16 to 28 cm H2O and increase in end-tidal carbon dioxide (ETCO2) from the initial value of 35 to 46 mmHg with normal wave morphology of the capnogram not touching the baseline, indicating toward rebreathing. The heart rate (HR) and mean arterial pressure (MAP) showed more than 25% variation from the baseline.
At this juncture the probable causes of the increased airway pressure such as excessive tidal volume, high inspiratory flow rate, kinking of endotracheal tube, and endobronchial intubation were ruled out and patient factors such as obesity, head down position, pneumoperitoneum, tension pneumothorax, and bronchospasm were also excluded.[3] On inspection, the faulty packing of soda lime canister was observed in both upper and lower canisters with 20% of space left empty. Moreover, there was a presence of totally exhausted soda lime in the upper canister, and the lower canister was warm to touch with water levels between the outer wall of the lower canister and the inner wall of the canister assembly [Figure 1]a and [Figure 1]b. Further to this, each time when the bellows moved, it resulted in water being sucked in and out of the canister with bubbling evident in the canister assembly [[Figure 1]a and [Video 1] (online)]. The soda lime was changed and when inspected revealed completely exhausted (white) dry soda lime granules of the upper canister in comparison to wet and less exhausted lower canister soda lime granules [Figure 1]b. Following the change of soda lime, patient's peak airway pressure, ETCO2, HR, and MAP stabilised and the rest of the surgery proceeded uneventfully.
Figure 1: (a) Excessive water bubbling between the outer wall of lower soda lime canister and the inner wall of the canister assembly. (b) The exhausted dry soda lime in the upper canister and the wet soda lime in the lower canister
Regeneration/peaking occurs because of surface regeneration of active hydroxides at the soda lime granules surface.[4] The amount of regeneration depends on the duration of rest given to soda lime and this may be the explanation of the reappearance of the original pink color next morning in our case after its continuous use a day before the incident.
Explanation for both rebreathing leading to hypercapnia and collection of excessive water could be due to channeling, which led to nonhomogenous flow of gases that occurs due to incorrect packing of soda lime in the canister.[1] The gas as well as the moisture collected from the exhaustion of the upper canister took the path of the least resistance forming channels and bypassing majority of the soda lime granules and hence moisture was collected in large quantity by gravity into the canister assembly. Presence of the excessive moist granules led to the phenomenon called "caking," which increased the peak airway pressure in our case.[2],[5] Therefore, careful marking of the date of change on the canister alone cannot guarantee prevention of such phenomenon, but utmost vigilance, care during refilling of canister, and knowing the total duration of use of the soda lime the day before the surgery should help in preventing such incidents.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Yamakage M, Takahashi K, Takahashi M, Satoh JI, Namiki A. Performance of four carbon dioxide absorbents in experimental and clinical settings. Anaesthesia 2009;64:287-92.
Displaced paediatric central venous catheter causing extravasation of intravenous fluid due to relatively longer gap between the distal and proximal lumens
Nishith Govil1, Mridul Dhar1, Kesari Masaipeta1, Intezar Ahmed2 1 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India 2 Department of Paediatric Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
Date of Web Publication
11-Feb-2019
Correspondence Address: Dr. Mridul Dhar Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand India
Source of Support: None, Conflict of Interest: None
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DOI: 10.4103/ija.IJA_674_18
How to cite this article: Govil N, Dhar M, Masaipeta K, Ahmed I. Displaced paediatric central venous catheter causing extravasation of intravenous fluid due to relatively longer gap between the distal and proximal lumens. Indian J Anaesth 2019;63:157-9
How to cite this URL: Govil N, Dhar M, Masaipeta K, Ahmed I. Displaced paediatric central venous catheter causing extravasation of intravenous fluid due to relatively longer gap between the distal and proximal lumens. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 12];63:157-9. Available from: http://www.ijaweb.org/text.asp?2019/63/2/157/251981
Sir,
A 4-month-old female child weighing 6 kg was posted for surgical excision of a sacrococcygeal teratoma. Pre-anaesthetic evaluation revealed no other significant history or findings on examination. On the day of surgery, the child was taken into the operation theatre and general anaesthesia was induced uneventfully. After discussion with surgical team, decision was taken to place a central venous catheter (CVC) as the patient had difficult peripheral venous access and was also going to require a relatively longer duration of IV antibiotics.
A 4.5-French, 6-cm double-lumen CVC (Vygon®) was inserted into the right internal jugular vein (IJV) under ultrasound guidance (USG). The catheter was introduced using over the wire Seldinger technique and position was confirmed by smooth aspiration of blood from both ports and visualization of catheter tip in the IJV lumen on USG. The catheter was fixed at 5 cm at the skin using the secondary fixation wing, as the blood flow was achieved at ~ 1.5 cm during initial puncture with the introducer needle. After securing the catheter with sutures and flushing the catheter with heparinised saline, the patient was turned prone for the surgery with the head turned sideways. IV fluid was not given through the central line intraoperatively. The surgery and eventual recovery were uneventful. Backflow of blood from the catheter during aspiration was confirmed once more at the end of the surgery.
Two hours post-operatively, IV fluids were initiated via the central line (proximal port). Soon after starting the fluid, the child developed a swelling in the submandibular region, which was soft, gradually increasing in size and tender to touch [Figure 1]. The IV fluid was stopped immediately, and a chest X-ray and USG examination of the swelling was ordered. The chest X-ray revealed a neck swelling which was more on the right side. The CVC appeared to be in place but seemed to have curved slightly in the subcutaneous tissue [Figure 2]. USG of the neck was suggestive of fluid collection in the subcutaneous plane and the catheter tip was still visible in the IJV lumen. The catheter was removed and a gentle compression was given on the swelling. The swelling subsided to near normal after 7–8 h. On examination of the catheter, it was observed that the proximal lumen was almost 2 cm from the tip of the catheter [Figure 3].
Figure 1: Submandibular swelling following fluid infusion
Central venous access is often required in younger paediatric patients during elective surgeries.[1] Although technically challenging, it offers a smooth intra- and post-operative course and avoidance of multiple pricks. Sizes of CVCs ranging from 3 to 5.5 french are available commercially. Cases of displaced and migrated CVC's have been reported and are quite common especially in the paediatric population.[2]
In the current case, it was hypothesised that the even though the initial placement of the CVC was correct, it could have migrated and curved during prone positioning due to sideways turning of the head; or subsequently during the post-operative period when the child was actively moving her neck. As the distance of the proximal lumen was nearly 2 cm from the tip, it could have led to slipping of the proximal lumen in and out of the IJV into the subcutaneous tissue; even though the rest of the catheter was still inside the vein.
Paediatric CVC's of different makers have varied specifications and different arrangement of lumens. In the present case, the CVC had a relatively longer gap between the proximal lumen and the distal tip, which increased the chances of the proximal lumen slipping out of the vein. When deciding the depth of insertion of CVC's in paediatric patients, in addition to the age- and height-based formulas,[3] one should also consider the arrangement and distance of the various lumens from the tip to minimise chances of CVC mal-positioning and prevent inadvertent extravasation of IV fluid or drugs into subcutaneous tissue.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Roldan CJ, Paniagua L. Central venous catheter intravascular malpositioning: Causes, prevention, diagnosis, and correction. West J Emerg Med 2015;16:658-64.
Andropoulos DB, Bent ST, Skjonsby B, Stayer SA. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001;93:883-6.
Medical care of transgender patients is not only legally bound but also ethically required. Globally, 0.5%–0.9% of the adult population exhibits a gender different from their birth sex, but there is a dearth of transgender-friendly hospitals stemming from ignorance to disdain for this marginalised community. With gradually increasing acceptance of the transgender patients in the society, healthcare professionals must gear up to deal with issues specific and unique to this group of population. These concerns remain important to understand for an optimal perioperative care. The medical concerns transcend international boundaries, whereas legal, social, economic and psychological concerns vary from place to place. There is a need for modification of curriculum and training for healthcare personnel to foster sensitivity and empathy in patient dealing, to allow for an unbiased optimal healthcare. Such patients require a thorough assessment in a comfortable environment considering their specific needs. A plan for perioperative care needs to be done and discussed with the patient and the perioperative care team as well. There is scarce literature with regard to perioperative care in the transgender patients and hence requires more research.
Background and Aims: Transcranial electrical stimulation (TES) elicited intraoperative motor evoked potentials (iMEPs), are suppressed by most anaesthetic agents. This prospective randomised study was carried out to compare the effects of Isoflurane and Propofol on iMEPs during surgery for spinal cord tumours. Methods: A total of 110 patients were randomly divided into two groups. In group P, anaesthesia was maintained with intravenous propofol (6.6 ± 1.5 mg/kg/hr) and in group I anaesthesia was maintained with isoflurane (0.8 ± 0.1% minimal alveolar concentration (MAC). An Oxygen- air mixture (FiO2-0.3) was used in both groups. TES-iMEPs were recorded from tibialis anterior, quadriceps, soleus and external anal sphincter muscles in 60 of 90 patients. Statistical analysis was performed with Pearson correlation and Paired 't' tests. Results: Successful baseline iMEPs were recorded in 74% of patients in Group P and in 50% of patients in Group I. Age and duration of symptoms influenced the elicitation of baseline iMEPs under isoflurane (r = −0.71, −0.66 respectively, P < 0.01) as compared to propofol (r = −0.60, −0.50 respectively, P < 0.01). The mean stimulus strength required to elicit the baseline iMEPs were lesser in propofol (205 ± 55Volts) as compared to isoflurane (274 ± 60 Volts). Suppression of the iMEP responses was less under propofol (7.3%) as compared to isoflurane anaesthesia (11.3%) in patients with no preoperative neurological deficits. Conclusion: iMEPs are better maintained under propofol anaesthesia (6-8 mg/kg/hr) when compared with isoflurane (0.7-0.9 MAC). in patients undergoing surgery for excision of spinal cord tumours.
Background and Aims: Direct laryngoscopy and tracheal intubation is a noxious stimulation that induces significant stress response. Currently, this nociceptive response is assessed mainly by haemodynamic changes. Recently, analgesia nociception index (ANI) is introduced into anaesthesia practice and provides objective information about parasympathetic (low nociceptive stress) and sympathetic (high nociceptive stress) balance, which reflects the degree of intraoperative nociception/analgesia. This study evaluated the changes in ANI and haemodynamics during anaesthetic induction and intubation, and their correlation during tracheal intubation. Methods: Sixty adult patients scheduled for elective brain tumour surgery under general anaesthesia were studied for changes in ANI, heart rate (HR) and mean blood pressure (MBP) during anaesthetic induction and intubation. This was a secondary analysis of a previously published trial. Linear mixed effects model was used to evaluate changes in ANI, HR and MBP and to test correlation between ANI and haemodynamics. Results: Anaesthetic induction reduced ANI (but not below the critical threshold of nociception of 50) and MBP, and increased the HR (P < 0.001). Direct laryngoscopy and tracheal intubation resulted in increase in HR and MBP with decrease in ANI below the threshold of 50 (P < 0.001). A linear negative correlation was observed between ANI and HR; r = −0.405, P < 0.001, and ANI and MBP; r = −0.415, P= 0.001. Conclusion: Significant changes are observed in ANI during anaesthetic induction and intubation. There is a negative linear correlation between ANI and systemic haemodynamics during intubation.
Background and Aims: Recently, low-dose intravenous (IV) dexmedetomidine has been evaluated for obtunding the pneumoperitoneum-induced haemodynamic changes and its analgesic efficacy in laparoscopic cholecystectomy. The aim was to determine the postoperative analgesic efficacy of low-dose bolus of 0.5 μg/kg dexmedetomidine via IV and intraperitoneal (IP) route in laparoscopic cholecystectomy. Methods: Seventy-five patients, aged 18–60 years of ASA physical status I and II, undergoing laparoscopic cholecystectomy under general anaesthesia were included. Patients in Group C received IP bupivacaine. Patients in Group IV received 0.5 μg/kg dexmedetomidine infusion IV after removal of gall bladder along with IP bupivacaine and Group IP received 0.5 μg/kg dexmedetomidine in 40 mL of 0.25% bupivacaine IP. The primary outcome was 'time to first request of analgesia' and the secondary outcomes were 'total consumption of tramadol in 24 hours,' visual analogue scale (VAS) pain score. Results: In total, 75 patients with 25 in each group were included. Time to first request of analgesia was found to be significantly lower in IV (59.68 ± 71.05 min, P= 0.00) and IP group (90.80 ± 80.46 min, P = 0.001) compared tp Group C (59.68 ± 71.05 min). Mean tramadol consumption in 24 hours (152.40 ± 60.958 vs 137.64 ± 52.40 mg) and mean VAS pain score were comparable in both IV and IP groups in the initial 12 h. Conclusion: Low bolus dose of IP dexmedetomidine is as efficacious as IV dexmedetomidine (0.5 μg/kg) along with IP bupivacaine in laparoscopic cholecystectomy.
Background and Aims: Use of ultrasound (US) during internal jugular vein (IJV) cannulation reduces the risk of associated complications in children under general anaesthesia. We studied the effect of two varieties of supraglottic airway device (SGAD), the Ambu AuraOnce™ LMA (Ambu LMA), and i-gel™ on the anatomical relationship between IJV and common carotid artery (CCA). Both these SGAD are known to have similar safety profile in paediatric age group. Methods: A total of 62 children were randomly allocated into 2 groups. In group L: Ambu AuraOnce™ LMA (Ambu LMA) and in group I: i-gel™ was inserted. After induction of GA, US images were taken with head in neutral and 30 degrees rotated to the opposite side both before and after insertion of SGAD. The relationship between IJV and CCA was noted as lateral, anterolateral, and anterior. Degree of overlap between the two vessels was also noted. Results: Lateral rotation of the head significantly alters the relationship between the IJV and CCA and also increases the degree of overlap between them. Though these changes were noted to be similar with both varieties of SGAD, but between the two varieties of SGAD, these changes were significantly higher in group I. Conclusion: Higher oesophageal sealing pressure exerted by i-gel™ as compared to other SGAD might cause increased distortion of the surrounding soft tissue leading to altered anatomical relationship between IJV and CCA, which makes the CCA vulnerable to puncture during IJV cannulation using landmark technique.
Background and Aims: Blood transfusion is unpredictable in liver transplantation and is associated with increased patient morbidity, mortality and cost. This retrospective analysis was conducted to detect factors which could predict intraoperative transfusion of more than four units of packed red blood cells (PRBCs) during elective living donor liver transplantation (LDLT). Methods: This was a single-centre retrospective study. Demographic, clinical and intraoperative data of 258 adult patients who underwent LDLT from March 2009 to January 2015 were analysed. Univariate and multivariate regression model was used to identify factors responsible for transfusion of more than four PRBCs (defined as massive transfusion [MT]). Results: On univariate regression analysis, preoperative factors like aetiology of liver disease, hypertension, history of spontaneous bacterial peritonitis, low haemoglobin and fibrinogen, high serum bilirubin, high blood urea and creatinine, high model for end-stage liver disease score, portal venous thrombosis, increased duration of surgery and anhepatic phase as well as increased use of other blood products were found to be significantly associated with MT. Multivariate logistic regression analysis revealed that the only independent factor associated with MT was the number of units of fresh frozen plasma transfused (odds ratio = 1.54 [95% CI (1.12–2.12)]). Conclusion: Many factors are responsible for the need for transfusion during LDLT. Preoperative factors alone do not accurately and consistently predict the need for MT as in our study. It is important to be prepared for need for MT during each transplant.
Background and Aims: Using remifentanil–propofol target-controlled infusion (TCI) in open gynaecological surgeries could be associated with opioid-induced hyperalgesia postoperatively. This study's aim was to investigate the effect of low-dose S-ketamine compared with control on cumulative morphine consumption 24 h postoperatively in women undergoing open abdominal hysterectomy with remifentanil–propofol TCI technique. Methods: Ninety female patients above 21 years old who underwent elective open abdominal hysterectomy under general anaesthesia with remifentanil–propofol TCI were recruited. They were randomised to receive either normal saline as control (n = 44) or 0.25 mg/kg intravenous boluses of S-ketamine before skin incision and after complete removal of uterus (n = 45). The primary outcome measure was cumulative morphine consumption measured over 24 h postoperatively. The secondary outcome measures were incidences of opioid-related and psychotomimetic side effects, pain and level of sedation scores. Results: The cumulative 24-h morphine consumption postoperatively (P = 0.0547) did not differ between both the groups. S-ketamine group had slower emergence from general anaesthesia (P = 0.0308) and lower pain scores (P = 0.0359) 15 min postoperatively. Sedation level, common opioid-related side effects (nausea, vomiting, pruritus), respiratory depression and psychotomimetic side effects were similar between both the study groups. Conclusion: Low-dose S-ketamine did not reduce the total cumulative morphine consumption in patients undergoing major open gynaecological surgeries with remifentanil–propofol TCI.
Peritoneal carcinomatosis is intraperitoneal spread of gastrointestinal and gynaecological cancers. Cytoreductive surgeries and hyperthermic intraperitoneal chemotherapy offers survival benefits in these cases. Spread of peritoneal carcinomatosis to thorax pose challenges to surgeon and anaesthesiologist. Haemodynamic, temperature and coagulopathy monitoring as well as intraoperative airway pressure, pre- and postoperative pulmonary function test monitoring is required in these cases where diaphragm excision is done and intraoperative intra peritoneal as well as pleural chemotherapy is given. We are reporting a case of pseudomyxoma peritonei involving the abdomen and left side of pleura and lung, posted for cytoreductive surgery and hyperthemic chemotherapy to abdomen and thorax, i.e., hyperthemic intraoperative thoraco-abdominal chemotherapy.
Medical care of transgender patients is not only legally bound but also ethically required. Globally, 0.5%–0.9% of the adult population exhibits a gender different from their birth sex, but there is a dearth of transgender-friendly hospitals stemming from ignorance to disdain for this marginalised community. With gradually increasing acceptance of the transgender patients in the society, healthcare professionals must gear up to deal with issues specific and unique to this group of population. These concerns remain important to understand for an optimal perioperative care. The medical concerns transcend international boundaries, whereas legal, social, economic and psychological concerns vary from place to place. There is a need for modification of curriculum and training for healthcare personnel to foster sensitivity and empathy in patient dealing, to allow for an unbiased optimal healthcare. Such patients require a thorough assessment in a comfortable environment considering their specific needs. A plan for perioperative care needs to be done and discussed with the patient and the perioperative care team as well. There is scarce literature with regard to perioperative care in the transgender patients and hence requires more research.
The effects of propofol and isoflurane on intraoperative motor evoked potentials during spinal cord tumour removal surgery - A prospective randomised trial
p. 92
Parthiban Velayutham, Verghese T Cherian, Vedantam Rajshekhar, Krothapalli S Babu DOI:10.4103/ija.IJA_421_18
Background and Aims: Transcranial electrical stimulation (TES) elicited intraoperative motor evoked potentials (iMEPs), are suppressed by most anaesthetic agents. This prospective randomised study was carried out to compare the effects of Isoflurane and Propofol on iMEPs during surgery for spinal cord tumours. Methods: A total of 110 patients were randomly divided into two groups. In group P, anaesthesia was maintained with intravenous propofol (6.6 ± 1.5 mg/kg/hr) and in group I anaesthesia was maintained with isoflurane (0.8 ± 0.1% minimal alveolar concentration (MAC). An Oxygen- air mixture (FiO2-0.3) was used in both groups. TES-iMEPs were recorded from tibialis anterior, quadriceps, soleus and external anal sphincter muscles in 60 of 90 patients. Statistical analysis was performed with Pearson correlation and Paired 't' tests. Results:Successful baseline iMEPs were recorded in 74% of patients in Group P and in 50% of patients in Group I. Age and duration of symptoms influenced the elicitation of baseline iMEPs under isoflurane (r = −0.71, −0.66 respectively, P < 0.01) as compared to propofol (r = −0.60, −0.50 respectively, P < 0.01). The mean stimulus strength required to elicit the baseline iMEPs were lesser in propofol (205 ± 55Volts) as compared to isoflurane (274 ± 60 Volts). Suppression of the iMEP responses was less under propofol (7.3%) as compared to isoflurane anaesthesia (11.3%) in patients with no preoperative neurological deficits. Conclusion: iMEPs are better maintained under propofol anaesthesia (6-8 mg/kg/hr) when compared with isoflurane (0.7-0.9 MAC). in patients undergoing surgery for excision of spinal cord tumours.
Analgesia nociception index and systemic haemodynamics during anaesthetic induction and tracheal intubation: A secondary analysis of a randomised controlled trial
Background and Aims: Direct laryngoscopy and tracheal intubation is a noxious stimulation that induces significant stress response. Currently, this nociceptive response is assessed mainly by haemodynamic changes. Recently, analgesia nociception index (ANI) is introduced into anaesthesia practice and provides objective information about parasympathetic (low nociceptive stress) and sympathetic (high nociceptive stress) balance, which reflects the degree of intraoperative nociception/analgesia. This study evaluated the changes in ANI and haemodynamics during anaesthetic induction and intubation, and their correlation during tracheal intubation. Methods:Sixty adult patients scheduled for elective brain tumour surgery under general anaesthesia were studied for changes in ANI, heart rate (HR) and mean blood pressure (MBP) during anaesthetic induction and intubation. This was a secondary analysis of a previously published trial. Linear mixed effects model was used to evaluate changes in ANI, HR and MBP and to test correlation between ANI and haemodynamics. Results: Anaesthetic induction reduced ANI (but not below the critical threshold of nociception of 50) and MBP, and increased the HR (P < 0.001). Direct laryngoscopy and tracheal intubation resulted in increase in HR and MBP with decrease in ANI below the threshold of 50 (P < 0.001). A linear negative correlation was observed between ANI and HR; r = −0.405, P < 0.001, and ANI and MBP; r = −0.415, P= 0.001. Conclusion: Significant changes are observed in ANI during anaesthetic induction and intubation. There is a negative linear correlation between ANI and systemic haemodynamics during intubation.
Comparison of postoperative analgesic efficacy of low-dose bolus intravenous dexmedetomidine and intraperitoneal dexmedetomidine with bupivacaine in patients undergoing laparoscopic cholecystectomy: A randomised, controlled trial
Background and Aims: Recently, low-dose intravenous (IV) dexmedetomidine has been evaluated for obtunding the pneumoperitoneum-induced haemodynamic changes and its analgesic efficacy in laparoscopic cholecystectomy. The aim was to determine the postoperative analgesic efficacy of low-dose bolus of 0.5 μg/kg dexmedetomidine via IV and intraperitoneal (IP) route in laparoscopic cholecystectomy. Methods: Seventy-five patients, aged 18–60 years of ASA physical status I and II, undergoing laparoscopic cholecystectomy under general anaesthesia were included. Patients in Group C received IP bupivacaine. Patients in Group IV received 0.5 μg/kg dexmedetomidine infusion IV after removal of gall bladder along with IP bupivacaine and Group IP received 0.5 μg/kg dexmedetomidine in 40 mL of 0.25% bupivacaine IP. The primary outcome was 'time to first request of analgesia' and the secondary outcomes were 'total consumption of tramadol in 24 hours,' visual analogue scale (VAS) pain score. Results: In total, 75 patients with 25 in each group were included. Time to first request of analgesia was found to be significantly lower in IV (59.68 ± 71.05 min, P= 0.00) and IP group (90.80 ± 80.46 min, P = 0.001) compared tp Group C (59.68 ± 71.05 min). Mean tramadol consumption in 24 hours (152.40 ± 60.958 vs 137.64 ± 52.40 mg) and mean VAS pain score were comparable in both IV and IP groups in the initial 12 h. Conclusion: Low bolus dose of IP dexmedetomidine is as efficacious as IV dexmedetomidine (0.5 μg/kg) along with IP bupivacaine in laparoscopic cholecystectomy.
Ultrasonographic assessment of altered anatomical relationship between internal jugular vein and common carotid artery with supraglottic airway in children: LMA vs i-gel™
Background and Aims: Use of ultrasound (US) during internal jugular vein (IJV) cannulation reduces the risk of associated complications in children under general anaesthesia. We studied the effect of two varieties of supraglottic airway device (SGAD), the Ambu AuraOnce™ LMA (Ambu LMA), and i-gel™ on the anatomical relationship between IJV and common carotid artery (CCA). Both these SGAD are known to have similar safety profile in paediatric age group. Methods: A total of 62 children were randomly allocated into 2 groups. In group L: Ambu AuraOnce™ LMA (Ambu LMA) and in group I: i-gel™ was inserted. After induction of GA, US images were taken with head in neutral and 30 degrees rotated to the opposite side both before and after insertion of SGAD. The relationship between IJV and CCA was noted as lateral, anterolateral, and anterior. Degree of overlap between the two vessels was also noted. Results: Lateral rotation of the head significantly alters the relationship between the IJV and CCA and also increases the degree of overlap between them. Though these changes were noted to be similar with both varieties of SGAD, but between the two varieties of SGAD, these changes were significantly higher in group I. Conclusion: Higher oesophageal sealing pressure exerted by i-gel™ as compared to other SGAD might cause increased distortion of the surrounding soft tissue leading to altered anatomical relationship between IJV and CCA, which makes the CCA vulnerable to puncture during IJV cannulation using landmark technique.
Predicting packed red blood cell transfusion in living donor liver transplantation: A retrospective analysis
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Shweta A Singh, Kelika Prakash, Sandeep Sharma, An Anil, Viniyendra Pamecha, Guresh Kumar, Ajeet Bhadoria DOI:10.4103/ija.IJA_401_18
Background and Aims: Blood transfusion is unpredictable in liver transplantation and is associated with increased patient morbidity, mortality and cost. This retrospective analysis was conducted to detect factors which could predict intraoperative transfusion of more than four units of packed red blood cells (PRBCs) during elective living donor liver transplantation (LDLT). Methods:This was a single-centre retrospective study. Demographic, clinical and intraoperative data of 258 adult patients who underwent LDLT from March 2009 to January 2015 were analysed. Univariate and multivariate regression model was used to identify factors responsible for transfusion of more than four PRBCs (defined as massive transfusion [MT]). Results: On univariate regression analysis, preoperative factors like aetiology of liver disease, hypertension, history of spontaneous bacterial peritonitis, low haemoglobin and fibrinogen, high serum bilirubin, high blood urea and creatinine, high model for end-stage liver disease score, portal venous thrombosis, increased duration of surgery and anhepatic phase as well as increased use of other blood products were found to be significantly associated with MT. Multivariate logistic regression analysis revealed that the only independent factor associated with MT was the number of units of fresh frozen plasma transfused (odds ratio = 1.54 [95% CI (1.12–2.12)]). Conclusion: Many factors are responsible for the need for transfusion during LDLT. Preoperative factors alone do not accurately and consistently predict the need for MT as in our study. It is important to be prepared for need for MT during each transplant.
Low-dose S+ ketamine in target-controlled intravenous anaesthesia with remifentanil and propofol for open gynaecological surgery: A randomised controlled trial
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Farida Binte Ithnin, Daryl Jian An Tan, Xue Lian Xu, Chin How Tan, Rehena Sultana, Ban Leong Sng DOI:10.4103/ija.IJA_605_18
Background and Aims: Using remifentanil–propofol target-controlled infusion (TCI) in open gynaecological surgeries could be associated with opioid-induced hyperalgesia postoperatively. This study's aim was to investigate the effect of low-dose S-ketamine compared with control on cumulative morphine consumption 24 h postoperatively in women undergoing open abdominal hysterectomy with remifentanil–propofol TCI technique. Methods: Ninety female patients above 21 years old who underwent elective open abdominal hysterectomy under general anaesthesia with remifentanil–propofol TCI were recruited. They were randomised to receive either normal saline as control (n = 44) or 0.25 mg/kg intravenous boluses of S-ketamine before skin incision and after complete removal of uterus (n = 45). The primary outcome measure was cumulative morphine consumption measured over 24 h postoperatively. The secondary outcome measures were incidences of opioid-related and psychotomimetic side effects, pain and level of sedation scores. Results: The cumulative 24-h morphine consumption postoperatively (P = 0.0547) did not differ between both the groups. S-ketamine group had slower emergence from general anaesthesia (P = 0.0308) and lower pain scores (P = 0.0359) 15 min postoperatively. Sedation level, common opioid-related side effects (nausea, vomiting, pruritus), respiratory depression and psychotomimetic side effects were similar between both the study groups. Conclusion: Low-dose S-ketamine did not reduce the total cumulative morphine consumption in patients undergoing major open gynaecological surgeries with remifentanil–propofol TCI.
Perioperative management of cytoreductive surgery and hyperthermic intraoperative thoraco-abdominal chemotherapy (HITAC) for pseudomyxoma peritonei
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Sohan Lal Solanki, Jhanvi S Bajaj, Febin Rahman, Avanish P Saklani DOI:10.4103/ija.IJA_825_18
Peritoneal carcinomatosis is intraperitoneal spread of gastrointestinal and gynaecological cancers. Cytoreductive surgeries and hyperthermic intraperitoneal chemotherapy offers survival benefits in these cases. Spread of peritoneal carcinomatosis to thorax pose challenges to surgeon and anaesthesiologist. Haemodynamic, temperature and coagulopathy monitoring as well as intraoperative airway pressure, pre- and postoperative pulmonary function test monitoring is required in these cases where diaphragm excision is done and intraoperative intra peritoneal as well as pleural chemotherapy is given. We are reporting a case of pseudomyxoma peritonei involving the abdomen and left side of pleura and lung, posted for cytoreductive surgery and hyperthemic chemotherapy to abdomen and thorax, i.e., hyperthemic intraoperative thoraco-abdominal chemotherapy.
Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases
Anaesthetic management of bilateral temporomandibular joint ankylosis with cervical spine fusion for total alloplastic joint replacement in a patient with ankylosing spondylitis
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Saurav , Shalendra Singh, S Kiran, Alok Jaiswal DOI:10.4103/ija.IJA_573_18
Displaced paediatric central venous catheter causing extravasation of intravenous fluid due to relatively longer gap between the distal and proximal lumens
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Nishith Govil, Mridul Dhar, Kesari Masaipeta, Intezar Ahmed DOI:10.4103/ija.IJA_674_18
Erratum: Optic nerve sheath diameter-guided extubation plan in obese patients undergoing robotic pelvic surgery in steep Trendelenburg position: A report of three cases
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