Journal of Anaesthesiology, Clinical Pharmacology最新文献

Background and aims: Thoracic epidural insertion has high failure rates in the mid-thoracic region due to steep angulation of oblique bending of spinous processes. The preferred skin puncture point for epidural needle insertion in the paramedian sagittal plane with respect to the superior/inferior tip of spinous process or inter-spinous cleft in the mid-thoracic region (T5-8) is not standard. The primary objective of this prospective observational study was to find the skin puncture point which had the best success rate for a successful epidural catheterization. Secondary objectives were to study the number of attempts and passes required to locate epidural space, incidence of failed epidural, and its relationship with patient characteristics and demographics.

Material and methods: After informed consent, 155 patients planned for general anesthesia with epidural analgesia in the mid-thoracic region were included in the trial. Patient demographics, the details of epidural attempts with respect to anatomical landmarks, distance from the midline, and number of passes in each attempt were noted. Epidural catheterization was considered successful after demonstrating dermatomal band of sensory blockade.

Results: The success rate at different skin puncture sites was not statistically significant (P = 0.58). We found a failure rate of 12.9%. Failed epidural catheterization was significantly high in the age group >56 years (n = 62 and P = 0.007).

Conclusion: In our study, none of the skin puncture points had a significant association with successful epidural insertion in mid-thoracic segments using a para-median approach.

Background and aims: Ventilator-associated pneumonia (VAP) is a nosocomial infection associated with high morbidity and mortality. This study was undertaken to monitor the trend of the demographical details, comorbid conditions, bacterial etiological agents, and their antibiogram causing VAP in adults in the year 2008, 2013 and 2018.

Material and methods: A retrospective study conducted at the Department of Microbiology, Hospital Infection control and Quality Control at a tertiary care teaching hospital. All the adult patients with more than 48 h of the mechanical ventilator with endotracheal intubation with Clinical Pulmonary infection Score >6 with suspicion of VAP were included in the study at a difference of 5 years, i.e., 2008, 2013, and 2018.

Results: A total of 338 patients were included in the study, of which males accounted for more than two-third of the patients studied. Nearly 45% of the patients belonged to geriatric (>60 years) age group. The most common comorbid conditions were chronic obstructive pulmonary disease, hypertension and diabetes mellitus. Among the gram-negative isolates, Klebsiella pneumoniae, Acinetobacter species, and Pseudomonas aeruginosa were the most common. There is an emergence of resistance to most commonly administered antimicrobial agents like aminoglycosides, levofloxacin, piperacillin/tazobactum, and carbapenems during the study period.

Conclusion: This is a ten-year study on the antibiotic resistance pattern of organisms causing VAP. As far as the authors are aware, this is the first study addressing the pattern of change in drug resistance in the organisms causing VAP over a decade. The emergence of multi-drug resistant (MDR) MDR pathogens, especially in intensive care unit (ICU), is a great concern for the intensivist and infection control physicians. Preventive measures need to be undertaken to control the spread of these pathogens to the patients in the ICU.

Anesthesiology, as an occupation, has its own unique sets of challenges, problems, issues, and circumstances, all leading to "occupational stress," which by now should be unequivocally accepted as a well-established fact. It is futile to continue pursuing research questions like, if there "really" is stress existing among practicing anesthesiologists/trainees, by conducting questionnaire-based surveys and doing meta-analyses. A significantly high incidence of existence of occupational stress in anesthesiologists is an undisputable and practical reality, which, when longstanding, gets culminated into "burnout syndrome" with its disastrous outcomes. Rather than pursuing the often-trodden path of finding the incidence, sources, and other superficial issues, an in-depth study of available literary evidence in relation to burnout has been carried out. Objectifying it as a "syndrome," its etiopathogenesis, pathophysiology inclusive of the prevalent theories of its causality, typology, and progression into various stages of/continuum of the process as an evolving clinical entity have been described. The preventive measures and "coping strategies" have been discussed at length in the end. It is the fervent hope and the desire of the authors that this discourse will sensitize all anesthesiologists, especially the younger and upcoming future generation, and help them avoid becoming a prey to this dreadful entity!

Background and aims: Squint surgery is a risk factor for postoperative vomiting (POV) in children. This study was designed to compare the incidence of POV in children undergoing strabismus surgery under balanced anesthesia with sevoflurane versus intravenous anesthesia with propofol.

Material and methods: In this prospective randomized controlled study conducted in a tertiary care ophthalmology hospital, 70 ASA I-II children aged 1-12 years undergoing strabismus surgery were randomized to two groups -Group S (sevoflurane-based anesthesia) and Group P (propofol-based anesthesia) for maintenance. The surgical details, intraoperative hemodynamic parameters, recovery characteristics, and emergence delirium were recorded. Any episode of postoperative vomiting in the 0-2 hours, 2-6 hours, and 6-24 hours period was noted. Rescue antiemetic was administered if there was more than one episode of vomiting.

Results: Both the groups were similar with respect to demographic and surgical details. The average duration of surgery was 118.2 ± 41.88 min in group S and 137.32 ± 39.09 min in group P (P = .05). Four children in group S (11.4%) and one child in group P (2.9%) had POV in the first 24 hours but this was not statistically significant (P = .36). The median time to discharge from post anesthesia care unit was significantly less (P = .02) in the P group (50 min) than in the S group (60 min).

Conclusion: Propofol-based anesthesia does not offer advantage over sevoflurane, in reducing POV after squint surgery, when dual prophylaxis with dexamethasone and ondansetron is administered. It, however, reduces the duration of stay in the post anesthesia care unit.

Background and aims: Modified radical mastectomy (MRM) is associated with moderate severity of postoperative pain. Besides intravenous (IV) analgesics, various nerve blocks are being described for pain relief of MRM patients. We compared erector spinae plane (ESP) block with midpoint transverse process to pleura (MTP) block in these patients for postoperative analgesia.

Material and methods: After receiving ethical committee approval from the institutional ethics committee (AIIMS, Jodhpur) and written informed consent from study participants, 66 patients who were assigned American Society of Anesthesiologists (ASA) physical status I and II, aged 18-75 years, and were scheduled to undergo MRM were enrolled and randomly allocated into two groups. Unilateral block was given before surgery at T3 or T4 level and with 15 ml of 0.5% ropivacaine in both the groups. Infusion of 0.5% ropivacaine (Neon laboratories limited, Mumbai, India) and 0.2% ropivacaine at a rate of 5 ml/h was maintained intraoperatively and postoperatively, respectively. Pain was assessed using the Visual Analogue Scale (VAS) for the next 24 hours. The total number of patients needing rescue analgesia, the total amount of rescue analgesics consumed in the next 24 hours, and patient satisfaction score were also compared between groups.

Results: Demographics and baseline vitals were comparable in the groups. On comparing VAS scores in both the groups during rest and movement at different time intervals, there was no difference in pain scores during the initial two hours. From the third hour, there was a statistically significant difference (P < 0.001) in pain VAS scores in both groups. The ESP group had lower VAS scores compared to the MTP group when followed for the next 24 hours. There was a statistically significant difference in patient satisfaction.

Conclusion: ESP block is more efficacious when compared to MTP block for postoperative analgesia in MRM patients.

Background and aims: To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP), hamstring stretch (HSP), classical sitting (CSP) and riders sitting position (RSP). The primary objective of this study was to measure the neuraxial acoustic target window (defined as interlaminar distance between L3-L4 lamina). The secondary objective was to compare ultra-sonographic measurements of the depth of ligamentum flavum from the skin, and to compare the diameter of intrathecal space and comfort score in the four different sitting positions.

Material and methods: This study is a prospective observational study. Eighty participants were included and positioned in four different sitting positions to perform an ultra-sonographic scan and measure various parameters of the acoustic neuraxial window. The interlaminar distance, the distance of skin from the ligamentum flavum, and the diameter of the spinal canal or intrathecal space was measured in the L3-L4 intervertebral space in different positions.

Results: The mean value of interlaminar distance among four sitting positions was ranging from 1.40 cm to 1.44 cm (P value 0.725.) The distance of ligamentum flavum from skin and diameter of intrathecal space was also comparable in all the groups. The comfort score in CSP was significantly better when compared to other groups with a median score of 4 (P value < 0.001).

Conclusions: There is no statistically significant difference in interlaminar distance in various sitting positions. All four positions are equally effective and can be used as an alternative to spinal/epidural intervention, but the CSP came out to be the most comfortable and more emphasis should be given to the comfort as it increases the chance of success rate of the procedure.

Background and aims: Perioperative variable parameters can be significant risk factors for postoperative intensive care unit (ICU) admission after elective craniotomy for intracranial neoplasm, as assessed by various scoring systems such as Cranio Score. This observational study evaluates the relationship between these factors and early postoperative neurological complications necessitating ICU admission.

Material and methods: In total, 119 patients, aged 18 years and above, of either sex, American Society of Anesthesiologists (ASA) grades I-III, scheduled for elective craniotomy and tumor excision were included. The primary objective was to evaluate the relationship between perioperative risk factors and the incidence of early postoperative complications as a means of validation of the Cranio Score. The secondary outcomes studied were 30-day postoperative morbidity/mortality and the association with patient-related risk factors.

Results: Forty-five of 119 patients (37.82%) required postoperative ICU care with the mean duration of ICU stay being 1.92 ± 4.91 days. Tumor location (frontal/infratemporal region), preoperative deglutition disorder, Glasgow Coma Scale (GCS) less than 15, motor deficit, cerebellar deficit, midline shift >3 mm, mass effect, tumor size, use of blood products, lateral position, inotropic support, elevated systolic/mean arterial pressures, and duration of anesthesia/surgery were associated with a higher incidence of ICU care. Maximum (P = 0.035, AOR = 1.130) and minimum systolic arterial pressures (P = 0.022, Adjusted Odds Ratio (AOR) = 0.861) were the only independent risk factors. Cranio Score was found to be an accurate predictor of complications at a cut-off point of >10.52%. The preoperative motor deficit was the only independent risk factor associated with 30-day morbidity (AOR = 4.66).

Conclusion: Perioperative hemodynamic effects are an independent predictor of postoperative ICU requirement. Further Cranio Score is shown to be a good scoring system for postoperative complications.

Cervical sympathetic or stellate ganglion blocks (SGBs) have been commonly used in the treatment of painful conditions like complex regional pain syndrome (CRPS). However, there is literature to suggest its utility in managing non-painful conditions as well. The focus of this literature review is to provide an overview of indications for SGB for painful and non-painful conditions. We identified published journal articles in the past 25 years from Embase and PubMed databases with the keywords "cervical sympathetic block, stellate ganglion blocks, cervical sympathetic chain, and cervical sympathetic trunk". A total of 1556 articles were obtained from a literature search among which 311 articles were reviewed. Among painful conditions, there is a lack of evidence in favor of or against the use of SGB for CRPS despite its common use. SGB can provide postoperative analgesia in selective surgeries and can be effective in temporary pain control of refractory angina and the acute phase of herpes zoster infection. Among non-painful conditions, SGB may have beneficial effects on the management of post-traumatic stress disorder (PTSD), refractory ventricular arrhythmias, hot flashes in postmenopausal women, and breast cancer-related lymphedema. Additionally, there have been various case reports illustrating the benefits of SGB in the management of cerebral vasospasm, upper limb erythromelalgia, thalamic and central post-stroke pain, palmar hyperhidrosis, orofacial pain, etc. In our review of literature, we found that SGB can be useful in the management of various non-painful conditions beyond the well-known treatment for CRPS, although further studies are required to prove its efficacy.

Background and aims: Coronavirus disease (COVID-19)-related pneumonia is proposed to be an inflammatory process. The treatment currently includes supportive therapy and low-dose steroids. Anti-inflammatory drugs have been proposed to prevent cytokine storms and improve oxygenation in such cases. The study aimed to assess the efficacy of nebulized lignocaine in COVID-19 patients with pneumonia.

Material and methods: This was an exploratory randomized double-blinded control trial conducted in COVID-19 patients with respiratory failure requiring oxygen therapy either by face mask or non-invasive mechanical ventilation. Patients included were of the age of more than 18 years of either gender. The patients were randomized to receive either lignocaine or distilled water nebulization. The outcomes assessed were PaO₂/FiO₂ ratio, hemodynamics, respiratory parameters, and sequential organ failure score (SOFA).

Results: The two groups were comparable concerning demographic variables. The PaO₂/FiO₂ were significantly higher in the lignocaine group from day 2 onward. The SPO₂ was significantly higher on day 3 in the lignocaine group and thereafter there was no significant difference. Other hemodynamic, respiratory parameters, and SOFA scores showed no difference in both the groups.

Conclusion: Lignocaine nebulization improved oxygenation in COVID-19 patients and can be used as adjunctive therapy along with other supportive medications.