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. 2014 May-Jun;58(3):372–382.

Award Winning Abstracts from the ISA Annual National Conference at Guwahati, December 2013

Editor: Sabyasachi Das
PMCID: PMC4091028
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner, platform presentation: Late Dr. T.N. Jha Memorial and Dr. K.P. Chansoriya Medal and Traveling grant for PGs, ISACON 2013: Efficacy of extrafascial or subfascial deposition of local anaesthetic in ultrasound guided supraclavicular brachial plexus block: A randomized observer blinded comparative study

Suja Ray, T Sivashanmugam, M Ravishankar

Mahatma Gandhi Medical College and Research Institute, Pondicherry, India

Background and Aims: During regional anaesthesia, because of absence of clear cut fascial compartment to consistently separate the neural tissues from the epimysium of the surrounding muscles,the local anaesthetic (LA) tends to easily spread away from the target site leading to complications. The availability of LA at the target site comes down and hence,the efficacy of the LA may also come down. Subepineural deposition of local anaesthetics hastens the onset of blockade and prolongs the duration of analgesia in sciatic nerve block. This study was designed to evaluate the efficacy of U/S guided supraclavicular block when LAs are deposited in the conventional extrafascial (EF) plane and in subfascial (SF) plane.

Methods: 32 consecutive patients posted for emergency or elective elbow and below elbow surgeries were recruited. They were randomly allocated to one of the groups by sealed envelope technique and under U/S guidance supraclavicular brachial plexus block was performed using 23 gauge needle, attached to a 20 ml syringe via a three way by a 100 cm pressure monitoring line. The pressure developed during the conventional EF or SF injection of drug was monitored by a syringe pump (Injectomat MC Agilia® , Fresenius Kabi AG, Bad Homburg, Germany) attached to pressure monitoring line; the LA syringe was attached to remaining port of a three way connector. A mixture of LAs (12.5 ml each of 2% lignocaine with adrenaline and 0.5% bupivacaine) was uniformly used for both approaches. After satisfactory drug deposition under U/S guidance, the final needle removal time was noted as block time. Block characteristics were assessed by a blinded observer every 5 minutes for 30 minutes and at 2, 4, 6, 8, 10, 12, 24 post-operative hours. Readiness for surgery was defined as absence of surgical site pain while attempting motor manoeuvre, atleast scale 1 sensory block (assessed on a 3-point qualitative scale for perseverance of cold) and motor loss (assessed on 3-point qualitative scale) in the four nerve territory.

Results: In the SF group the time to readiness for surgery was significantly shorter (7 ± 3.0 min vs. 20 ± 10.1 min; P = 0.000) and the duration of analgesia was longer (561 ± 89 min vs. 367 ± 89 min; P = 0.000) when compared to EF group [Table 1]. None of the patients registered any persistent neurological changes at the end of 24 hrs. Subfascial deposition of local anaesthetic provided a shorter onset time for surgical anaesthesia due to less intra and extra neural diffusion time for the LA and prolonged analgesia as less surface area is available for systemic absorption of LA when compared to extrafascial deposition.

Table 1.

Block characteristics

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Conclusion: Subfascial deposition of LA provides faster onset of surgical anaesthesia and prolonged analgesia without any persistent neurological deficit at 24 hrs.

REFERENCES

  • 1.Tran de QH, Dugani S, Pham K, Al-Shaafi A, Finlayson RJ. A randomized comparison between subepineural and conventional ultrasound-guided popliteal sciatic nerve block. Reg Anesth Pain Med. 2011;36:548–52. doi: 10.1097/AAP.0b013e318235f566. [DOI] [PubMed] [Google Scholar]
  • 2.Morau D, Levy F, Bringuier S, Biboulet P, Choquet O, Kassim M, Bernard N, Capdevila X. Ultrasound-guided evaluation of the local anaesthetic spread parameters required for a rapid surgical popliteal sciatic nerve block. Reg Anesth Pain Med. 2010;35:559–64. doi: 10.1097/AAP.0b013e3181fa6b60. [DOI] [PubMed] [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner (first prize): Ish - Narani Best Poster Award for PGs: Effects of irrigation fluid in shoulder arthroscopy

Surbhi Gupta, M Manjuladevi, KS Vasudeva Upadhyaya, AM Kutappa, J Arpana

Amravathi Rajkumar. St. John's Medical College and Hospital, Bengaluru, Karnataka, India

Background and Aims: Irrigation fluid used in shoulder arthroscopy has the potential to migrate into adjacent soft tissues and systemic circulation leading to complications. The primary objective was to study the effect of irrigation fluid absorption on measurable parameters. The secondary objective was to identify whether these parameters help in predicting airway/ respiratory compromise.

Methods: In this prospective, observational study, 32 patients of ASA physical status I-II, aged 15-60 years undergoing shoulder arthroscopy under general anesthesia in lateral decubitus position were included. The measured parameters preoperatively and postoperatively were neck, chest, mid-arm and thigh circumference, weight, haemoglobin (Hb) and serum sodium. Temperature, endotracheal tube cuff pressure and airway pressure were measured throughout the procedure. Normal saline was used as irrigation fluid, with pump pressure of 40-80 mmHg and flow rate between 50-150 ml/min. Duration of surgery, amount of irrigation and intravenous fluid used were noted. Post surgery, endotracheal tube cuff leak test was performed. Subjective feeling of breathlessness and tightness in neck and chest, inability to phonate, increase in respiratory rate, chest retractions, stridor, cyanosis and decrease in SpO2 were used as indicators of airway/respiratory compromise. Studied parameters were analyzed using paired t-test and correlation between the variables assessed using Spearman's rank correlation test.

Results: Postoperatively, mean values for neck, chest, midarm, thigh circumference and weight increased significantly [Figure 1]. There was a significant decrease in haemoglobin levels and body temperature. Correlation was observed between the changes in the neck circumference, haemoglobin and weight with the volume of irrigation fluid used and the duration of surgery. No patients in our study showed any symptoms or signs of airway/respiratory compromise.

Figure 1.

Figure 1

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Comparison of preoperative and postoperative measured variables

Conclusion: Regional and systemic absorption of irrigation fluid in shoulder arthroscopy can be predicted by measurable parameters. An increase in surgical time may increase the volume of irrigation fluid used and absorbed. Evaluation of degree of change in these parameters in patients with respiratory/ airway complications may help in evolving a scoring system to predict such complications in future.

REFERENCES

  • 1.Manjuladevi M, Gupta S, Vasudeva Upadhyayab K S, Kutappa A M. Postoperative airway compromise in shoulder arthroscopy: A case series. Indian J Anaesth. 2013;57:52–5. doi: 10.4103/0019-5049.108563. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Gogia AR, Bajaj J, Sahni A, Saigal D. Negative-pressure pulmonary oedema in a patient undergoing shoulder arthroscopy. Indian J Anaesth. 2012;56:62–5. doi: 10.4103/0019-5049.93347. [DOI] [PMC free article] [PubMed] [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner (second prize): Ish - Narani Best Poster Award for PGs: Effect of dexmedetomidine added to hyperbaric spinal bupivacaine for infra-umbilical procedures

Rohini Dattatri, Safiya I Shaikh

Karnataka Institute of Medical Sciences, Hubli

Background and Aims: Various adjuncts have been used to prolong the analgesic effect of intrathecal bupivacaine. Dexmedetomidine, an alpha adrenoreceptor agonist used as neuraxial adjuvant provides stable haemodynamic conditions, good quality of intra-operative and prolonged post-operative analgesia with minimal side effects. We aimed to compare two doses of dexmedetomidine (0.005 mg and 0.01 mg) added to hyperbaric bupivacaine on block characteristics after spinal anaesthesia with respect to onset and duration of sensory and motor block. Secondary objectives were to study the haemodynamic effect, the duration of analgesia and the occurrence of side effects.

Methods: 90 adult patients scheduled for below umbilicus surgeries were randomly assigned into 3 groups, each receiving 3.5 ml spinal injectate that consisted of 3 ml of 0.5 % hyperbaric bupivacaine and 0.5 ml volume containing either 0.005mg dexmedetomidine (group D1), 0.01mg dexmedetomidine (group D2) or normal saline (group B). Heart rate, arterial blood pressure, onset and regression of sensory and motor block, level of sedation were assessed. Time to rescue analgesia was noted. The incidence of adverse effects was recorded. Statistical tests used were Chi-Square test, ANOVA, Tukeys multiple post hoc test and SPSS version 20.

Results: The mean time taken for the sensory block to reach T10 dermatome [Figure 1] and motor block to reach Bromage 3 grade was significantly rapid in dexmedetomidine groups as compared to bupivacaine group (B vs D1, B vs D2, P < 0.001) and was faster in D2 group as compared to D1 group. The time taken for regression of sensory block to S1 dermatome and Bromage 0 grade motor block and the time to first rescue analgesic were increased significantly by addition of dexmedetomodine in a dose dependent manner (B vs D1, B vs D2 and D1 vs D2, P < 0.001). VRS scores were significantly lower in dexmedetomidine group as compared to bupivacaine group. No statistically significant differences in Ramsay sedation score, heart rate, blood pressure and respiratory rate was noted between the three groups.

Figure 1.

Figure 1

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Time to reach T10 sensory block-Comparison of Groups B, D1 and D2 (mins)

Conclusion: Addition of dexmedetomidine to hyperbaric bupivacaine intrathecally produces a rapid onset of sensory and motor block, prolongs the sensory and motor block and the time to first rescue analgesic requirement significantly in a dose dependent manner together with stable haemodynamic parameters, minimal sedation and side effects.

REFERENCE

  • 1.Gupta R, Bogra J, Verma R, Kohli M, Kushwaha JK, Kumar S. Dexmedetomidine as an intrathecal adjuvant for post-operative analgesia. Indian J Anesth. 2011;55:347–51. doi: 10.4103/0019-5049.84841. [DOI] [PMC free article] [PubMed] [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner (third prize): Ish - Narani Best Poster Award for PGs: Awareness of scope of anaesthesiology, attitudes towards the specialty and stress levels among postgraduate students in anaesthesiology: A cross sectional study

Chaitanya A. Kamat1, Mahantesh Todakar2, S. Rangalakshmi3, Pawan3

1JNMC, Belgaum, 2Public Health Officer, Dharwad, 3RRMCH, Bangalore, Karnataka, India

Background and Aims: Trends in selection of a career in medicine vary from country to country. Choosing a career is a complex exercise and wrong choice may result in multiple consequences and to plan future recruitment strategies, each country needs to examine these reasons as part of educational research. The aim of this study was to explore the Anaesthesiology postgraduate student's awareness about scope of specialty, their attitude towards the specialty, stress levels, views regarding Diploma course and undergraduate exposure to the subject.

Methods: We distributed 800 pretested questionnaires to the anaesthesia postgraduates at various conferences in India during 2011 and 2012. The answers relating to scope of and attitude towards the specialty, stress levels, views regarding Diploma course and undergraduate exposure to the subject were analyzed statistically using SPSS version 20.

Results: Out of a total of 702 postgraduates who returned the questionnaires, 31.6% of the students were unaware of scope of Anaesthesiology and only 42.3% of students joined the specialty out of the interest to learn the subject whereas 55.7% joined for other reasons including unavailability of other specialties during medical postgraduate counseling (21.8%). 70% of students indicated that they were stressed out during post-graduation, 31.6% found difficulty in accommodating the demands of challenging job, 3.8% went into depression. 57% of the students opined that Diploma in Anaesthesia was not a viable career option and should be scrapped [Figure 1]. The results highlight the need to emphasize on the positive aspects of the specialty and scope outside the operating room like trauma, critical care and pain management.

Figure 1.

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Reasons for selecting Anaesthesia as a career

Conclusion: There was marked dearth of information, confusion and insecurity among the student community regarding the specialty. Professional bodies such as the Indian Society of Anaesthesiologists along with Medical universities and the statutory bodies (Medical council of India) should take up the issues, reform the rules and regulations regarding undergraduate curriculum, postgraduate working hours and status of Diploma course in Anaesthesiology.

REFERENCES

  • 1.Mary G Harris, Paul H Gavel, Jeannette R Young. Factors influencing the choice of speciality of Australian medical graduates. Med J Aust. 2005;183:295–300. doi: 10.5694/j.1326-5377.2005.tb07058.x. [DOI] [PubMed] [Google Scholar]
  • 2.Shidhaye RV, Divekar DS, Dhulkhed VK, Goel G, Gupta A, Shidhaye R. Evaluation of stressors and coping strategies for stress in Indian anaesthesiologists. Indian J Anaesth. 2011;55:193–8. doi: 10.4103/0019-5049.79871. [DOI] [PMC free article] [PubMed] [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner: Dr. KOP's AWARD for speciality fora (Clinical Pharmacology): Effects of intrathecal dexmedetomidine added to low-dose bupivacaine for spinal anaesthesia in patients undergoing perianal surgeries

Aanchal Dixit, SS Harsoor, SS Nethra, D Devika Rani, K Sudheesh, Ashwini Turai

Bangalore Medical College and Research Institute, Bangalore, India

Background and Aims: The newer trend in regional anaesthesia for ambulatory anorectal surgeries is to use lower dose of local anaesthetic, provide segmental block and use adjuvants to potentiate analgesia. The aim of this study was to evaluate effects of intrathecal dexmedetomidine added to low-dose bupivacaine in patients undergoing perianal surgeries in ambulatory care.

Methods: In this prospective study, 40 patients scheduled for elective perianal surgeries were randomized into 2 groups; group D received dexmedetomidine 5 μg (0.5 ml) and group N received normal saline (0.5 ml), added to 6 mg of 0.5% hyperbaric bupivacaine (1.2 ml). Haemodynamic monitoring, sensory and motor blockade, Ramsay sedation scores were noted intra and post operatively. Time to ambulation and first voiding were noted.

Results: Time for regression of sensory level to below S1 (N–301.10 ± 94.86 min, D–430.05 ± 89.13 min) and time for first request of analgesia (N–321.85 ± 95.08 min, D–459.8 ± 100.9 min) were clinically and statistically prolonged in group D. Duration of motor blockade (N–220.10 ± 63.61 min, D–323.05 ± 54.58 min), time to ambulation (N–221.60 ± 63.84, D–329.55 ± 54.06 min) and time to voiding (N–328.45 ± 113.38, D–422.30 ± 87.59 min) were delayed in group D [Table 1]. Mean intraoperative sedation score was comparable in both groups.

Table 1.

Intraoperative and post-operative outcome parameters

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Conclusion: Dexmedetomidine 5 μg added to intrathecal bupivacaine 6 mg prolonged duration of sensory block, post-operative analgesia without change in sedation scores but time to ambulation was delayed.

REFERENCES

  • 1.Gudaityte J, Marchertiene I, Dainius P. Anesthesia for ambulatory anorectal surgery. Medicina. 2004;40:101–11. [PubMed] [Google Scholar]
  • 2.Abdelhamid SA, El-lakany MH. Intrathecal dexmedetomidine: Useful or not? J Anesth Clin Res. 2013;4:351. [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner: Dr. KOP's AWARD for speciality fora (Critical Care and Trauma): Efficacy of recombinant human erythropoietin in critically ill patients: A clinical study

Vivek Pushp, Shanti Vijay Mishra, Deepak Malviya, Satish Kumar, Raka

Rani. Nehru Hospital, B.R.D. Medical College Gorakhpur, Uttar Pradesh, India

Background and Aims: Anaemia is a common problem in critically ill patients admitted to ICU. Majority need blood transfusions during their stay which in itself is an independent risk factor for increased mortality. Among the alternative strategies, exogenous administration of Recombinant Human Erythropoietin (rHuEPO) is a promising modality. Our aim was to determine if the use of rHuEPO reduces the need of blood transfusions, increase Hb% and Hct% and to assess its dose titratability in critically ill patients depending on the desired goal.

Methods: This was a randomised controlled clinical trial conducted on 40 patients having respiratory failure with sepsis with anaemia, of either sex, and age ranging from 18-60 years. A thorough clinical assessment was performed in all patients before starting management. Patients anaemia profile (Hb%, Hct%, Reticulocyte count, S. Iron, S. ferritin, transferritin saturation) were obtained at admission, on 4th day and the day before discharge. Patients were divided randomly to 2 groups. Group1 received iron sucrose (400 mg elemental iron) in 2 divided doses twice a week. Group 2 received rHuEPO 4000 I.U. S/C + iron sucrose (100 mg elemental iron) in 2 divided doses twice a week. All patients also received mechanical ventilation through appropriate mode initially, as all were in respiratory failure when admitted along with vasopressor support as required.

Results: The average no. of PRBCs transfusion required was less in group 2 as compared to group 1 (P < 0.001). Statistically significant decrease in assisted ventilation days was found in group 2. The average increase in transferritin saturation in group 2 was significant as compared to group 1 (P = 0.0049). The average period of ICU stay in group 2 patients was less as compared to group 1 (P = 0.043) and the modified ODIN's (Organ Dysfunctions and/or Infection) score of group 2 patients was very significant as compared to group 1 (P < 0.001) [Figure 1].

Figure 1.

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Average no. of prbcs transfused

Conclusion: rHuEPO with iron therapy in critically ill patients decreased the length of ICU stay, decreased the need for blood transfusions, lessened the number of days of assisted ventilation as well as decreased the mortality. Recombinant human erythropoietin administration is very effective alternative treatment and preventive strategy for management of anaemia in critically ill patients.

REFERENCES

  • 1.von ashen N, Muller C, Serke S, Frei U, Eckardt KU. Important role of non diagnostic blood loss and blunted erythropoietic response in the anemia of medical intensive care patients. Crit Care Med. 1999;27:2630–39. doi: 10.1097/00003246-199912000-00005. [DOI] [PubMed] [Google Scholar]
  • 2.Shermock KM, Horn E, Lipsett PA. Number needed to treat and cost of recombinant human erythropoietin to avoid one transfusion related adverse event in critically ill patients. Crit Care Med. 2005;33:497–503. doi: 10.1097/01.ccm.0000155988.78188.ee. [DOI] [PubMed] [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner: Dr. KOP's AWARD for speciality fora (Pain and Palliative Care): Pregabalin for postoperative analgesia in laparoscopic cholecystectomy

R Nandi1, S Manimala Rao2

1Department of Anaesthesiology, LNJPH, Maulana Azad Medical College, New Delhi, 2Yashoda Hospital, Hyderabad

Background and Aims: Pain is a common complaint after elective laparoscopic cholecystectomy, and is the primary reason for prolonged hospital stay. A drug that has opioid-sparing analgesic effect, anxiolytic property, and is not associated with side effects like the commonly used analgesics would be an attractive option for premedication and postoperative pain management. The primary aim of the study was to evaluate a single preoperative dose of pregabalin for postoperative analgesia in laparoscopic cholecystectomy. A secondary objective was to determine if premedication with pregabalin would cause preoperative anxiolysis and perioperative sedation.

Methods: In this prospective, randomized, double-blind, placebo-controlled study, 60 patients (ASAPS I or II) were allocated randomly into study group (n = 30) or control group (n = 30). Study group was given oral pregabalin 150 mg (P150) 1 hour before surgery; control group was given placebo. General anaesthesia (GA) technique was standardized with fentanyl analgesia (IV). Visual analogue scale (VAS) and Ramsay Sedation Score (RSS) were used to assess pain and sedation, respectively, in the 24 hour postoperative period. Verbal Rating Scale (VRS) enabled patients to describe anxiety and side effects of pregabalin. t-test and ANOVA were used to analyze data.

Results: P150 given 1 hour before laparoscopic cholecystectomy significantly reduced intraoperative fentanyl requirement (P value = 0.006, 11% reduction relative to Placebo group), postoperative VAS scores, and requirement of “rescue” analgesic - tramadol ([P value = 0, 50% reduction relative to Placebo group) in the postoperative (24-hour) period. Time to first postoperative tramadol requirement was significantly more in P150 group [Table 1]. This study also demonstrated that single preoperative dose of P150 does not provide anxiolysis, but does produce more perioperative sedation as compared to Placebo group, and can cause mild and transient side effects (viz. somnolence, dizziness, and headache).

Table 1.

Postoperative tramadol requirement

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Conclusion: Preoperative oral pregabalin 150 mg reduced pain and opioid consumption in the postoperative 24-hour period following laparoscopic cholecystectomy. Side effects like sedation, dizziness, and headache (which may be prohibitive in daycare/ambulatory surgeries) are the limitations of its use.

REFERENCES

  • 1.Bisgaard T, Kehlet H, Rosenberg J. Pain and convalescence after laparoscopic cholecystectomy. Eur J Surg. 2001;167:84–96. doi: 10.1080/110241501750070510. [DOI] [PubMed] [Google Scholar]
  • 2.Bisgaard T, Klarskov B, Rosenberg J, Kehlet H. Factors determining convalescence after uncomplicated laparoscopic cholecystectomy. Arch Surg. 2001;136:917–21. doi: 10.1001/archsurg.136.8.917. [DOI] [PubMed] [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner: Dr. KOP's AWARD for speciality fora (Neuroanaesthesia): Evaluation of stroke volume variation as a guide in preoperative fluid therapy in patients undergoing intracranial surgeries

Zareena, P Mrunalini, Mastan Saheb, Vemuri Nagendra Nath

NRI Medical College Chinakakani, Guntur, India

Background and Aims: Outcomes after intracranial surgeries rely on maintenance of adequate intra-operative cerebral perfusion. Fluid optimization is a major determinant but is a double edged sword with risk of organ hypo-perfusion and oedema at both ends, either of which can prolong the ICU stay of such patients. Static indices like CVP, PCWP and LVED area are poor predictors of fluid responsiveness compared to dynamic ones like stroke volume (SV), stroke volume variation (SVV), cardiac output(CO) during mechanical ventilation. The Vigileo® device with FloTrac® sensor (Edwards Life Sciences), gives automatic and continuous display based on arterial pulse contour analysis without any external calibration via intra-arterial access. We aimed to evaluate the efficacy of SVV measured by Vigileo® Monitor/ FloTrac® device as an essential index of preload responsiveness and its reliability in assessing fluid status. We also determined the number of Volume loading steps (VLS) required to achieve fluid optimisation.

Methods: 53 patients of ASA I& II, undergoing craniotomy for an intracranial tumour removal or clipping of an aneurysm were enrolled and those with documented coronary or peripheral arterial disease, pulmonary disease and cardiac arrhythmias were excluded.

After a 5 min period of stable haemodynamic parameters post-intubation, each patient received successive VLS of 200 ml Ringer's lactate (RL), until the increase in SV was <10%. Blood pressure (BP), heart rate (HR), SV and SVV were measured before and after each VLS. The optimal preload augmentation required for each patient by the number of VLS after which SV increase was <10% was noted.

Results: There was a statistically significant difference in baseline BP and SVV between responsive and nonresponsive patients to first VLS along with significant correlation with change in SV before and after the first VLS. Receiver operating characteristic (ROC) analysis showed a larger area under the curve (AUC) of 0.758 for SVV [Figure 1]. The median number of VLS administered were 2 per patient equating to a mean ± SD of 368 ± 176 ml of crystalloid as the optimal preoperative infusion volume.

Figure 1.

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Graph showing ROCcurves for all the measured variables. Area under the curve being maximum for SVV

Conclusion: SVV obtained with 3rd generation Vigileo® monitor / FloTrac® device is a better predictor of preload responsiveness when compared to BP and HR. The above method may have an advantage over the conventional method of fluid administration based solely on the weight of the patient (ml/kg).

REFERENCES

  • 1.Li J, Ji FH, Yang JP. Evaluation of stroke volume variation obtained by the FloTrac/Vigileo system to guide preoperative fluid therapy in patients undergoing brain surgery. The Journal of International Medical Research. 2012;40:1175–1181. doi: 10.1177/147323001204000338. [DOI] [PubMed] [Google Scholar]
  • 2.Paul E Marik, Xavier Monnet, Jean-Louis Teboul. Hemodynamic parameters to guide fluid therapy. Annals of Intensive Care. 2011;1:1. doi: 10.1186/2110-5820-1-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner: Dr. KOP's AWARD for speciality fora (Obstetric Anaesthesia): Randomized double blind comparison of ephedrine and phenylephrine for management of post spinal hypotension with foetal compromise

Megha Aggarwal, Medha Mohta, AK Sethi, Priyanka Harisinghani

University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India

Background and Aims: Vasopressors are the mainstay of management of post-spinal hypotension during caesarean section. Ephedrine was for long considered a safe drug due to better preservation of uteroplacental circulation but phenylephrine later replaced it as the vasopressor of choice as it maintains foetal pH better than ephedrine. Most of the studies comparing these drugs have been conducted in healthy, low-risk, elective patients with no foetal compromise where small differences in fetal pH and uteroplacental perfusion are unlikely to have any clinical impact. With compromised foetuses, the margin of safety for uteroplacental perfusion may be reduced and even minor differences may become significant. The present study was conducted to compare ephedrine and phenylephrine in terms of haemodynamic changes, maternal complications and foetal acid-base status in presence of foetal compromise in mothers undergoing emergency caesarean section.

Methods: 60 ASA I/II pregnant females with compromised foetus were included in this prospective, randomized, double-blind study. Spinal anaesthesia was administered with 2.0-2.2 ml hyperbaric 0.5% bupivacaine. Post-spinal hypotension, defined as systolic blood pressure <100 mmHg, was treated with ephedrine 8 mg (n = 30) or phenylephrine 100 mcg (n = 30). Umbilical arterial and venous blood sampling was done after double clamping the cord before baby's first breath. APGAR scores were recorded at 1 and 5 minutes after birth. Any maternal complications were recorded and managed appropriately.

Results: Systolic blood pressure changes were comparable in both the groups. More patients developed bradycardia and heart rate was lower from three minutes onwards in phenylephrine group. There was no difference in neonatal outcome in terms of APGAR scores and foetal blood gas parameters including arterial pH, base deficit and incidence of foetal acidosis with ephedrine or phenylephrine [Table 1]. The incidence of maternal complications was also similar.

Table 1.

Neonatal Parameters

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Conclusion: Both ephedrine and phenylephrine are suitable vasopressors with similar maternal and foetal outcome to treat post-spinal hypotension in pregnant women with foetal compromise undergoing emergency caesarean section. Phenylephrine is associated with maternal bradycardia but this is easily treatable with anticholinergics and has no adverse effects on neonatal outcome.

REFERENCES

  • 1.Ngan Kee WD. Prevention of maternal hypotension after regional anaesthesia for caesarian section. Curr Opin Anaesthesiol. 2010;23:304–309. doi: 10.1097/ACO.0b013e328337ffc6. [DOI] [PubMed] [Google Scholar]
  • 2.Cooper DW, Sharma S, Orakkan P, Gurung S. Retrospective study of association between choice of vasopressor given during spinal anaesthesia for high-risk caesarean delivery and fetal pH. Int J Obstet Anaesth. 2010;19:44–49. doi: 10.1016/j.ijoa.2009.06.002. [DOI] [PubMed] [Google Scholar]
Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner: Dr. KOP's AWARD for speciality fora (Paediatric Anaesthesia): Comparison of effects of dexmedetomidine versus fentanyl on emergence agitation and recovery profiles after sevoflurane anaesthesia in paediatric patients

Rashmi Bawdekar, Mamta Patel, VN Swadia

Government Medical College, Vadodara, India

Background and Aims: Sevoflurane is a popular inhalation agent in paediatric patients because of its rapid onset and rapid recovery profile, non-irritating property on airway and excellent haemodynamic stability. Emergence agitation has been identified as a significant problem in children recovering after sevoflurane anaesthesia with a reported incidence up to 80%. It is a source of discomfort to not only to child but also to parents and nursing staff. We studied the efficacy of IV dexmedetomidine and IV fentanyl on attenuation of emergence agitation and on recovery profiles after sevoflurane anaesthesia in paediatric patients.

Methods: In this prospective,randomised,single blind study, a total of 60 ASA physical status I/II children aged 3-10 years undergoing lower abdominal surgery were randomly assigned to receive Inj. dexmedetomidine 0.3 mcg/kg (Group D), Inj.fentanyl 1 mcg/kg (Group F) and normal saline (Group C) after induction of anaesthesia with 8% sevoflurane. Haemodynamic parameters, agitation scale and recovery profiles were noted.

Results: The incidence of agitation (emergence agitation score > 4/5) was 20% in Group D, 25% in Group F and 85% in Group C. The emergence time was observed 9.3 ± 1.33 min in Group D, 8.72 ± 1.18 min in Group F and 6.28 ± 1.07 min in Group S [Table 1]. The recovery scores were higher in the control group in the first fifteen minutes of extubation, however the time to shift the child from operating room to recovery room and recovery room to the wards were comparable in all the three groups.

Table 1.

Emergence scores in three groups (5 point emergence agitation scale)

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Conclusion: Both dexmedetomidine 0.3 mcg/kg IV and fentanyl 1 mcg/kg IV are effective in reducing emergence agitation after sevoflurane anaesthesia in paediatric patients without causing any change in the recovery profiles.

REFERENCES

  • 1.Mauricio E. Ibacache, MD, Hernan R. Munoz, MD, Verena Brandes, MD, Anita L. Morales., RN Single-Dose Dexmedetomidine Reduces Agitation After Sevoflurane Anesthesia in Children. Anesth Analg. 2004;98:60–3. doi: 10.1213/01.ANE.0000094947.20838.8E. [DOI] [PubMed] [Google Scholar]
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Indian J Anaesth. 2014 May-Jun;58(3):372–382.

Winner: Dr. KOP's AWARD for speciality fora (Cardiac Anaesthesia): Ondansetron induced QT interval changes in induction with isoflurane and halothane in healthy subjects undergoing general anaesthesia

A Lahiri, S Duttagupta, S Gogia, S Banerjee

Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India

Background and Aims: Ondansetron, a serotonin receptor (5 HT3) antagonist is used routinely as an anti-emetic. One known major adverse effect is prolongation of the QT interval on ECG. This study is aimed to compare ondansetron induced QT interval changes during induction with isoflurane and halothane in healthy subjects undergoing general anaesthesia (GA).

Methods: In this prospective randomized study, 54 patients were randomly allocated to three groups: Group C (control) received ondansetron, Group H (halothane) received ondansetron and induction with halothane, Group I (isoflurane) received ondansetron and induction with isoflurane. Heart rate corrected QT interval (QTc) and haemodynamic parameters were measured at baseline (QTc1), immediately after giving ondansetron (QTc2) and post induction (QTc3).

Results: There was a statistically significant prolongation of the QTc interval after induction (QTc3) in Group C and Group I as compared to baseline QTc (QTc1) in these groups. The post induction QTc interval (QTc3) in group I showed statistically significant prolongation as compared to the group H [Figure 1]. This study shows that the patients receiving ondansetron are more prone to increase QTc during administration of isoflurane than halothane anaesthesia. The mean QTc of Group I shows a statistically significant prolongation from baseline QTc, hence producing an additive effect on QTc while using ondansetron and isoflurane together.

Figure 1.

Figure 1

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Comparison of Qtc at different time points

Conclusion: Concomitant use of isoflurane and ondansetron may prolong the QTc significantly; it is better to be on guard as risk of arrhythmias becomes more in predisposed patients.

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Articles from Indian Journal of Anaesthesia are provided here courtesy of Wolters Kluwer -- Medknow Publications

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