Journal of Neuroanaesthesiology and Critical Care, May 14, 2023
Background Phenytoin is a commonly used antiepileptic drug (AED) for postoperative seizure prophy... more Background Phenytoin is a commonly used antiepileptic drug (AED) for postoperative seizure prophylaxis; it is associated with adverse cardiovascular effects. Fosphenytoin is considered a safer alternative but can produce prolongation of QT interval. This hypothesis generating pilot study evaluated the changes in hemodynamics and the heart rate corrected QT interval (QTc) with phenytoin and fosphenytoin during propofol and sevoflurane anesthesia. Methods Eighty American Society of Anesthesiologists I and II patients aged 20 to 60 years undergoing elective supratentorial craniotomy requiring a loading dose of the intraoperative AED for seizure prophylaxis were randomized into four groups: group PP, receiving propofol (0.2 mg/kg/min) for maintenance and phenytoin (15 mg/kg) for seizure prophylaxis; group SP, receiving sevoflurane (1 minimal alveolar concentration) for maintenance and phenytoin(15mg/kg) for seizure prophylaxis; group PF, receiving propofol for maintenance and fosphenytoin (22.5 mg/kg) for seizure prophylaxis; and group SF, receiving sevoflurane for maintenance and fosphenytoin for seizure prophylaxis. The heart rate, systolic, diastolic, mean arterial pressure, and QTc were measured at baseline before anesthesia, during maintenance of anesthesia, and during various phases of AED infusion and up to 1 hour after completion of AED administration. Appropriate statistical analysis was done and a two-tailed p-value of less than 0.05 was considered significant. Results The incidence of changes in the heart rate and hypotension was not significant among the groups. Administration of fosphenytoin significantly prolonged QTc, which was more remarkable when coadministered with sevoflurane than with phenytoin.
Asian Journal of Pharmaceutical and Clinical Research, May 7, 2023
Methods: It was a prospective observational study carried out in a group of 100 patients, of whic... more Methods: It was a prospective observational study carried out in a group of 100 patients, of which 50 were males and 50 females. In both the groups, baseline entropy (response entropy [RE] and state entropy [SE]) and algesiometry values were recorded, 2 mic/kg of fentanyl was administered, and entropy values were recorded for 5 min and another algesiometry reading was taken at the end of 5 min. Results: Both the groups were found to be comparable age and weight (p<0.05). However, the mean height of male patients was found to be more as compared to females, and the difference was found to be statistically significant (p=0.037). There was no statistically significant difference in the American society of anesthesiologists grades of male and female patients (p=1). Comorbidities were analyzed using Pearson's Chi-square test and both the groups were comparable in terms of distribution of comorbidities. (p=1.000). All parameters such as heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, oxygen Saturation, RE, and SE at various time intervals were found to be comparable in male and female patients. There was no statistically significant difference in any of the parameters till 5 min after fentanyl administration (p>0.05). There was no significant difference in entropy values among males and females before and after fentanyl administration. Females had significantly (p=0.033) lower pain threshold and a statistically significant increase in pain threshold as compared to males after fentanyl administration (p=0.012). Conclusion: We conclude that fentanyl administration has not influenced the entropy values based on gender and females had an initial low pain threshold and a greater increase in pain threshold after fentanyl administration.
Journal of Anaesthesiology Clinical Pharmacology, Dec 23, 2022
Background and Aims: Intravenous induction agents like propofol and etomidate change the airway m... more Background and Aims: Intravenous induction agents like propofol and etomidate change the airway mechanics and thus influence mask ventilation. These changes have an impact on the administration of muscle relaxant in a difficult mask ventilation scenario. The difference in dynamics of airway after administration of two different intravenous agents has been assessed in this study. Material and Methods: After formal registry in clinical trials, patients undergoing general anesthesia were recruited and randomized into group P and E. Patients were induced with either of the intravenous agents, and mask ventilation was performed with a ventilator. After 60 s, rocuronium was administered and ventilation continued. Measurements of tidal volume, peak airway pressure, and compliance were taken from the anesthesia ventilator at different time points – induction, relaxant, and intubation. Results: There was no statistically significant difference between the two groups with respect to demographics, airway parameters, and airway mechanics, as measured by tidal volume, peak airway pressure, and lung compliance. There was an improvement in the tidal volume and compliance following induction with propofol, with a P value of 0.007 and 0.032, respectively, obtained in within-group comparison. Conclusion: Propofol and etomidate were comparable in airway mechanics, but compliance and tidal volumes improved with propofol, which facilitated face mask ventilation.
Purpose: Lumbar laminectomy is a commonly performed procedure in neurosurgical and orthopedic pra... more Purpose: Lumbar laminectomy is a commonly performed procedure in neurosurgical and orthopedic practice. Postoperative pain reliefhelps in early mobilization, initiation of physiotherapy, provides satisfaction to the patients and plays an important role in reducing the morbidity and mortality. This prospective study investigated the simple technique of instillation of wound with bupivacaine and leaving a contact time of 60 seconds on postoperative pain following lumbar laminectomy. Methods: 32 ASA I and II patients scheduled for laminectomy were randomly allocated to receive either 20 ml of normal saline (group I) or 0.25% of bupivacaine (group II) into the wound after securing hemostasis. After a dwell time of 60sec the wound was closed in layers without mopping or suctioning. After extubation, the pain scores were evaluated by visual analog scale at every 4 hrs. for 24hrs and also the time for first demand of analgesia, number of analgesic demands and the total amount of analgesia consumed were noted by an independent observer.. Results: The median duration of analgesia in group I was 8.8 [5-11] and in group II 13 [8.5-16] hrs. with a p = 0.04. The number of demands and the amount of analgesia consumed was also statistically significant. Conclusion: Wound instillation technique is simple, safe and effective in management of acute pain management after lumbar laminectomy and can be used as one among the multimodal armamentarium in pain management.
Background: Patients undergoing corrective surgery for scoliosis of spine are commonly ventilated... more Background: Patients undergoing corrective surgery for scoliosis of spine are commonly ventilated in our institute after the operation. Postoperative mechanical ventilation (PMV) and subsequent prolongation of intensive care unit stay are associated with increase in medical expenditure and complications such as ventilator-associated pneumonia. Identification of factors which may contribute to PMV and their modification may help in allocation of resources effectively. The present study was performed to identify preoperative and intraoperative factors associated with early PMV after scoliosis surgery. Methods: One hundred and two consecutive patients who underwent operation for scoliosis correction between January 2006 to July 2011 were reviewed retrospectively. Patients requiring PMV included patients who were not extubated in the operating room and were continued on mechanical ventilation. Preoperative and intraoperative factors which were analysed included age, gender, weight, cardiorespiratory function, presence of kyphosis, number and level of vertebrae involved, surgical approach, whether thoracoplasty was done, duration of surgery, blood loss, fluids and blood transfused, hypothermia and use of antifibrinolytics. Results: The average age of the patients was 14.31±3.78 years with female preponderance (57.8%). Univariate analysis found that longer fusions of vertebrae (more than 8), blood loss, amount of crystalloids infused, blood transfused and hypothermia were significantly associated with PMV (P<0.05). Independent risk factors for PMV were longer fusion (Odds Ratio (OR), 1.290; 95% confidence interval (CI), 1.038-1.604) and hypothermia (OR, 0.096; 95% CI, 0.036-0.254; P<0.05). Conclusion: The authors identified that longer fusions and hypothermia were independent risk factors for early PMV. Implementation of measures to prevent hypothermia may result in decrease in PMV.
Journal of Neuroanaesthesiology and Critical Care, 2016
There is an increasing concern regarding the risk of anesthetic-induced developmental neurotoxici... more There is an increasing concern regarding the risk of anesthetic-induced developmental neurotoxicity (AIDN) in children. Evidence has shown that exposure to most of the commonly used anaesthetic and sedatives can cause neurodegeneration in the developing brain. Anesthetic effects on the brain during its growth spurt can initiate a cascade of alterations in neurodevelopment, which can be detected structurally or functionally. Anesthetic exposure induces apoptosis and neurodegeneration in a dose and time-dependent fashion consistent with the pattern of N-methyl D-aspartate antagonism and gamma-amino butyric acid type A activation by these drugs. Understanding the cellular and molecular mechanisms of AIDN may help in developing methods that are safe and do not interfere with the beneficial properties of anaesthetic drugs and yet inactivate the intracellular signals that trigger neuroapoptosis.
Background and Aims: Chronic post thoracotomy pain (CPTP) is a nagging complication and can affec... more Background and Aims: Chronic post thoracotomy pain (CPTP) is a nagging complication and can affect quality of life (QOL). Studies conducted across globe have found a wide variability in the risk factors predisposing to chronic pain following thoracotomy. As no study on CPTP is available from India, we aim to detect the prevalence of CPTP, assess the predisposing factors implicated in its causation and study the impact of CPTP on QOL. Methods: After obtaining clearance from Institutional ethics committee, medical records of patients who underwent open posterolateral thoracotomy between January 2012 and December 2015 were reviewed. Data on perioperative variables, address, and contact number were collected from the patient records. All patients were mailed the Telugu translation of medical outcome study short form -36(MOS-SF-36) QOL questionnaire and were contacted telephonically to enquire about presence of CPTP and QOL. A univariate analysis was done to assess factors associated with CPTP and a multivariate logistic regression analysis was done subsequently to identify independent risk factors of CPTP. QOL indices were compared between those patients who suffered from CPTP and those who did not. Results: The prevalence of pain in our study was 40.86% (85/208). The factors implicated in the causation of CPTP were diabetes mellitus, preoperative pain, rib resection, and duration of chest tube drainage with odds ratio of 9.8, 2.6, 6.7, and 1.03, respectively. The health-related QOL showed poor scores in all domains in patients suffering from CPTP. Conclusion: The prevalence of CPTP was high. It significantly impacts health-related QOL.
Aims and Objectives: To validate the Parsonnet scoring model to predict mortality following adult... more Aims and Objectives: To validate the Parsonnet scoring model to predict mortality following adult cardiac surgery in Indian scenario. Materials and Methods: A total of 889 consecutive patients undergoing adult cardiac surgery between January 2010 and April 2011 were included in the study. The Parsonnet score was determined for each patient and its predictive ability for in-hospital mortality was evaluated. The validation of Parsonnet score was performed for the total data and separately for the subgroups coronary artery bypass grafting (CABG), valve surgery and combined procedures (CABG with valve surgery). The model calibration was performed using Hosmer-Lemeshow goodness of fit test and receiver operating characteristics (ROC) analysis for discrimination. Independent predictors of mortality were assessed from the variables used in the Parsonnet score by multivariate regression analysis. Results: The overall mortality was 6.3% (56 patients), 7.1% (34 patients) for CABG, 4.3% (16 patients) for valve surgery and 16.2% (6 patients) for combined procedures. The Hosmer-Lemeshow statistic was <0.05 for the total data and also within the subgroups suggesting that the predicted outcome using Parsonnet score did not match the observed outcome. The area under the ROC curve for the total data was 0.699 (95% confidence interval 0.62-0.77) and when tested separately, it was 0.73 (0.64-0.81) for CABG, 0.79 (0.63-0.92) for valve surgery (good discriminatory ability) and only 0.55 (0.26-0.83) for combined procedures. The independent predictors of mortality determined for the total data were low ejection fraction (odds ratio [OR]-1.7), preoperative intra-aortic balloon pump (OR-10.7), combined procedures (OR-5.1), dialysis dependency (OR-23.4), and re-operation (OR-9.4). Conclusions: The Parsonnet score yielded a good predictive value for valve surgeries, moderate predictive value for the total data and for CABG and poor predictive value for combined procedures.
Turkish journal of anaesthesiology and reanimation, Jun 24, 2021
Objective: Amino acids attenuate hypothermia during the perioperative period by increasing thermo... more Objective: Amino acids attenuate hypothermia during the perioperative period by increasing thermogenesis and stimulating energy consumption. Percutaneous nephrolithotomy (PCNL) induces profound hypothermia owing to the use of large volumes of irrigating fluids. The role of amino acids in this group of surgeries for hypothermia and shivering prevention has been evaluated in this study because there is no available literature of concern. Methods: This prospective randomised controlled trial was conducted in patients undergoing PCNL. Group A received amino acids at 60 mL h-1 an hour before surgery until the end of surgery. Group C received normal saline infusion. Perioperative nasopharyngeal temperature, haemodynamics, and postoperative shivering were recorded. Results: Although there was no significant difference in temperature in the intraoperative period, postoperative decrease in the temperature was less in the amino acid group. In the postoperative period, 2 patients in the amino acid group and 11 patients in the control group experienced shivering. Conclusion: Intravenous administration of amino acids attenuated postoperative hypothermia and reduced shivering in patients undergoing PCNL without any adverse effects.
Introduction: Local anaesthetics used in spinal anaesthesia have a limited duration of action. To... more Introduction: Local anaesthetics used in spinal anaesthesia have a limited duration of action. To prolong postoperative analgesia, adjuvants, mainly opioids, are used. As µ agonist drugs have side effects, other receptor agonists are considered. Nalbuphine is a safe and effective kappa agonist adjuvant. Aim: To compare the analgesic efficacy between fentanyl and nalbuphine adjuvants added to 3 mL of 0.5% intrathecal hyperbaric bupivacaine. Materials and Methods: This prospective, double-blind, comparative study was conducted in 60 patients of either sex belonging to the American Society of Anesthesiologists classes I and II aged 18–65 years undergoing lower limb surgery with entropy monitoring, randomly allocated into two groups. Group F (n = 30) received 0.5% hyperbaric bupivacaine (3 mL) + 25 µg (0.5 mL) fentanyl. Group N (n = 30) received 0.5% hyperbaric bupivacaine (3 ml) + 0.8 mg (0.5 mL) nalbuphine intrathecally. Hemodynamics, entropy, motor and sensory block characteristics, and complications were noted. Results: The nalbuphine group had a significantly longer two-segment regression time of sensory blockade and extended analgesia duration than the fentanyl group. Haemodynamics, entropy, time for onset of sensory and motor blockade and adverse effects were comparable in both groups. Conclusion: Nalbuphine prolongs sensory blockade and postoperative analgesia duration with minimal side effects and is a safe intrathecal adjuvant.
Therapeutic hypothermia has been advocated for neuroprotection in cardiac arrest-induced encephal... more Therapeutic hypothermia has been advocated for neuroprotection in cardiac arrest-induced encephalopathy, neonatal hypoxic-ischemic encephalopathy, traumatic brain injury, stroke, hepatic encephalopathy, and spinal cord injury, and as an adjunct to certain surgical procedures. In this review, we address physiological mechanism of hypothermia to mitigate neurological injury, the trials that have been performed for each of these indications, the strength of the evidence to support treatment with mild/moderate hypothermia. Evidence is strongest for prehospital cardiac arrest and neonatal hypoxicischemic encephalopathy. For traumatic brain injury, a recent meta-analysis suggests that cooling may increase the likelihood of a good outcome, but does not change mortality rates. For many of the other indications, such as stroke and spinal cord injury, trials are ongoing, but the data is insufficient to recommend routine use of hypothermia at this time. Although induced hypothermia appears to be a highly promising treatment, it should be emphasized that it is associated with a number of potentially serious side effects, which may negate some or all of its potential benefits. Prevention and/or early treatment of these complications are the key to successful use of hypothermia in clinical practice. various other disorders. The clinical use of TH is likely to increase in the near future; thus, anesthesiologists should have knowledge regarding the clinical applications of TH. The aim of this review was to describe the evidence for the use of therapeutic hypothermia in clinical practice. The impact of this therapy on outcome and methods for practice of hypothermia will be included in the review. A formal literature search was conducted using PubMed and Cochrane databases, to identify suitable original papers, meta-analysis and reviews. The search headings included the text words: Cerebral ischemia and hypothermia, therapeutic hypothermia and cardiac arrest and resuscitation, traumatic brain injury, neonatal hypoxic encephalopathy, cooling methods, outcome. The additional source of data was a hand search of references from relevant articles. Definition By definition, hypothermia is a body temperature less than 36 o C and it is divided into three stages: mild hypothermia, when the body temperature is between 35 o C-32 o C, moderate hypothermia when the body temperature is between 32 o C and 30 o C, and deep hypothermia when the body temperature is less than 30 o C. Therapeutic hypothermia is defined as a core temperature ≤ 35°C induced deliberately by artificial cooling, which is used to prevent or attenuate various forms of neurological injury [8]. Mechanisms underlying neuroprotective effects of Hypothermia Cerebral ischemia and subsequent reperfusion injury cause enormous biochemical, structural, and functional insults, which in a complex interrelated process leads to progressive cell destruction, neuronal apoptosis, and death [9]. Hypothermia has been shown to attenuate or ameliorate many of these deleterious temperaturesensitive mechanisms, thereby contributing to protection of the brain [10]. Many of the mechanisms underlying hypothermia's effects Dates:
Trends in Anaesthesia and Critical Care, Dec 1, 2017
Regional techniques at thoracic level for thoracotomy surgeries in infants are gaining wider acce... more Regional techniques at thoracic level for thoracotomy surgeries in infants are gaining wider acceptance. The principal focus is on preserving physiological stability and reducing postoperative pain and stress in these smaller individuals as they are more susceptible to impairment in pulmonary function. Knowledge about the drug pharmacokinetics, dynamics in this age group along with availablity of the adequate size equipment has revolutionised anesthesia in infants. This review focusses on the various techniques of regional anesthesia for thoracotomy in neonates and infants along with local anesthetics.
Prevalence of pulmonary thromboembolism (PTE) is very high when we compare the coronavirus diseas... more Prevalence of pulmonary thromboembolism (PTE) is very high when we compare the coronavirus disease 2019 positive patients with the other patients who are admitted in intensive care unit for other different infection. Thorough evaluation of the different causative factors for PTE should be better evaluated and prevention can be tried accordingly. Incidence of subclinical PTE that can give rise to future cardiac disease needs to be studied and plan of action can be done accordingly. Newer modalities of detecting PTE using non-invasive or simple invasive techniques need to be investigated to cope up in pandemic situation.
Sudden onset and de-novo Myasthenia gravis (MG) in the presence of systemic lupus erythematosus (... more Sudden onset and de-novo Myasthenia gravis (MG) in the presence of systemic lupus erythematosus (SLE) is a rare postpartum phenomenon and can easily misguide the treating physician. A known case of SLE, 4 days after an elective caesarean section, presented to the intensive care unit for weaning-off mechanical ventilation after being put on ventilatory support in the emergency room, following acute onset partial seizures. She was subsequently diagnosed to have new onset MG, treated for the condition and later successfully extubated.
The Journal of Clinical and Scientific Research, 2015
Background: Intravenous injection of lipid emulsion propofol induces a considerable degree of pai... more Background: Intravenous injection of lipid emulsion propofol induces a considerable degree of pain and the most preferred treatment suggested is pretreatment with intravenous lignocaine to alleviate such pain. The present study was designed to evaluate whether addition of metoclopramide to lignocaine offers any advantage over lignocaine alone as a pretreatment in prevention of pain following propofol injection. Methods: In this prospective, randomized, double-blind controlled study, 60 patients were randomized to receive either lignocaine (group A) or lignocaine with metoclopramide (group B) intravenously as a pretreatment before injection of propofol. Pain due to injection of propofol was assessed with a four point categorical verbal rating pain scale. The incidence and magnitude of pain was compared between the two groups. Results: There was no statistically significant difference in the perceived intensity of pain between the two groups at different time points after administrati...
Journal of Neuroanaesthesiology and Critical Care, May 14, 2023
Background Phenytoin is a commonly used antiepileptic drug (AED) for postoperative seizure prophy... more Background Phenytoin is a commonly used antiepileptic drug (AED) for postoperative seizure prophylaxis; it is associated with adverse cardiovascular effects. Fosphenytoin is considered a safer alternative but can produce prolongation of QT interval. This hypothesis generating pilot study evaluated the changes in hemodynamics and the heart rate corrected QT interval (QTc) with phenytoin and fosphenytoin during propofol and sevoflurane anesthesia. Methods Eighty American Society of Anesthesiologists I and II patients aged 20 to 60 years undergoing elective supratentorial craniotomy requiring a loading dose of the intraoperative AED for seizure prophylaxis were randomized into four groups: group PP, receiving propofol (0.2 mg/kg/min) for maintenance and phenytoin (15 mg/kg) for seizure prophylaxis; group SP, receiving sevoflurane (1 minimal alveolar concentration) for maintenance and phenytoin(15mg/kg) for seizure prophylaxis; group PF, receiving propofol for maintenance and fosphenytoin (22.5 mg/kg) for seizure prophylaxis; and group SF, receiving sevoflurane for maintenance and fosphenytoin for seizure prophylaxis. The heart rate, systolic, diastolic, mean arterial pressure, and QTc were measured at baseline before anesthesia, during maintenance of anesthesia, and during various phases of AED infusion and up to 1 hour after completion of AED administration. Appropriate statistical analysis was done and a two-tailed p-value of less than 0.05 was considered significant. Results The incidence of changes in the heart rate and hypotension was not significant among the groups. Administration of fosphenytoin significantly prolonged QTc, which was more remarkable when coadministered with sevoflurane than with phenytoin.
Asian Journal of Pharmaceutical and Clinical Research, May 7, 2023
Methods: It was a prospective observational study carried out in a group of 100 patients, of whic... more Methods: It was a prospective observational study carried out in a group of 100 patients, of which 50 were males and 50 females. In both the groups, baseline entropy (response entropy [RE] and state entropy [SE]) and algesiometry values were recorded, 2 mic/kg of fentanyl was administered, and entropy values were recorded for 5 min and another algesiometry reading was taken at the end of 5 min. Results: Both the groups were found to be comparable age and weight (p<0.05). However, the mean height of male patients was found to be more as compared to females, and the difference was found to be statistically significant (p=0.037). There was no statistically significant difference in the American society of anesthesiologists grades of male and female patients (p=1). Comorbidities were analyzed using Pearson's Chi-square test and both the groups were comparable in terms of distribution of comorbidities. (p=1.000). All parameters such as heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, oxygen Saturation, RE, and SE at various time intervals were found to be comparable in male and female patients. There was no statistically significant difference in any of the parameters till 5 min after fentanyl administration (p>0.05). There was no significant difference in entropy values among males and females before and after fentanyl administration. Females had significantly (p=0.033) lower pain threshold and a statistically significant increase in pain threshold as compared to males after fentanyl administration (p=0.012). Conclusion: We conclude that fentanyl administration has not influenced the entropy values based on gender and females had an initial low pain threshold and a greater increase in pain threshold after fentanyl administration.
Journal of Anaesthesiology Clinical Pharmacology, Dec 23, 2022
Background and Aims: Intravenous induction agents like propofol and etomidate change the airway m... more Background and Aims: Intravenous induction agents like propofol and etomidate change the airway mechanics and thus influence mask ventilation. These changes have an impact on the administration of muscle relaxant in a difficult mask ventilation scenario. The difference in dynamics of airway after administration of two different intravenous agents has been assessed in this study. Material and Methods: After formal registry in clinical trials, patients undergoing general anesthesia were recruited and randomized into group P and E. Patients were induced with either of the intravenous agents, and mask ventilation was performed with a ventilator. After 60 s, rocuronium was administered and ventilation continued. Measurements of tidal volume, peak airway pressure, and compliance were taken from the anesthesia ventilator at different time points – induction, relaxant, and intubation. Results: There was no statistically significant difference between the two groups with respect to demographics, airway parameters, and airway mechanics, as measured by tidal volume, peak airway pressure, and lung compliance. There was an improvement in the tidal volume and compliance following induction with propofol, with a P value of 0.007 and 0.032, respectively, obtained in within-group comparison. Conclusion: Propofol and etomidate were comparable in airway mechanics, but compliance and tidal volumes improved with propofol, which facilitated face mask ventilation.
Purpose: Lumbar laminectomy is a commonly performed procedure in neurosurgical and orthopedic pra... more Purpose: Lumbar laminectomy is a commonly performed procedure in neurosurgical and orthopedic practice. Postoperative pain reliefhelps in early mobilization, initiation of physiotherapy, provides satisfaction to the patients and plays an important role in reducing the morbidity and mortality. This prospective study investigated the simple technique of instillation of wound with bupivacaine and leaving a contact time of 60 seconds on postoperative pain following lumbar laminectomy. Methods: 32 ASA I and II patients scheduled for laminectomy were randomly allocated to receive either 20 ml of normal saline (group I) or 0.25% of bupivacaine (group II) into the wound after securing hemostasis. After a dwell time of 60sec the wound was closed in layers without mopping or suctioning. After extubation, the pain scores were evaluated by visual analog scale at every 4 hrs. for 24hrs and also the time for first demand of analgesia, number of analgesic demands and the total amount of analgesia consumed were noted by an independent observer.. Results: The median duration of analgesia in group I was 8.8 [5-11] and in group II 13 [8.5-16] hrs. with a p = 0.04. The number of demands and the amount of analgesia consumed was also statistically significant. Conclusion: Wound instillation technique is simple, safe and effective in management of acute pain management after lumbar laminectomy and can be used as one among the multimodal armamentarium in pain management.
Background: Patients undergoing corrective surgery for scoliosis of spine are commonly ventilated... more Background: Patients undergoing corrective surgery for scoliosis of spine are commonly ventilated in our institute after the operation. Postoperative mechanical ventilation (PMV) and subsequent prolongation of intensive care unit stay are associated with increase in medical expenditure and complications such as ventilator-associated pneumonia. Identification of factors which may contribute to PMV and their modification may help in allocation of resources effectively. The present study was performed to identify preoperative and intraoperative factors associated with early PMV after scoliosis surgery. Methods: One hundred and two consecutive patients who underwent operation for scoliosis correction between January 2006 to July 2011 were reviewed retrospectively. Patients requiring PMV included patients who were not extubated in the operating room and were continued on mechanical ventilation. Preoperative and intraoperative factors which were analysed included age, gender, weight, cardiorespiratory function, presence of kyphosis, number and level of vertebrae involved, surgical approach, whether thoracoplasty was done, duration of surgery, blood loss, fluids and blood transfused, hypothermia and use of antifibrinolytics. Results: The average age of the patients was 14.31±3.78 years with female preponderance (57.8%). Univariate analysis found that longer fusions of vertebrae (more than 8), blood loss, amount of crystalloids infused, blood transfused and hypothermia were significantly associated with PMV (P<0.05). Independent risk factors for PMV were longer fusion (Odds Ratio (OR), 1.290; 95% confidence interval (CI), 1.038-1.604) and hypothermia (OR, 0.096; 95% CI, 0.036-0.254; P<0.05). Conclusion: The authors identified that longer fusions and hypothermia were independent risk factors for early PMV. Implementation of measures to prevent hypothermia may result in decrease in PMV.
Journal of Neuroanaesthesiology and Critical Care, 2016
There is an increasing concern regarding the risk of anesthetic-induced developmental neurotoxici... more There is an increasing concern regarding the risk of anesthetic-induced developmental neurotoxicity (AIDN) in children. Evidence has shown that exposure to most of the commonly used anaesthetic and sedatives can cause neurodegeneration in the developing brain. Anesthetic effects on the brain during its growth spurt can initiate a cascade of alterations in neurodevelopment, which can be detected structurally or functionally. Anesthetic exposure induces apoptosis and neurodegeneration in a dose and time-dependent fashion consistent with the pattern of N-methyl D-aspartate antagonism and gamma-amino butyric acid type A activation by these drugs. Understanding the cellular and molecular mechanisms of AIDN may help in developing methods that are safe and do not interfere with the beneficial properties of anaesthetic drugs and yet inactivate the intracellular signals that trigger neuroapoptosis.
Background and Aims: Chronic post thoracotomy pain (CPTP) is a nagging complication and can affec... more Background and Aims: Chronic post thoracotomy pain (CPTP) is a nagging complication and can affect quality of life (QOL). Studies conducted across globe have found a wide variability in the risk factors predisposing to chronic pain following thoracotomy. As no study on CPTP is available from India, we aim to detect the prevalence of CPTP, assess the predisposing factors implicated in its causation and study the impact of CPTP on QOL. Methods: After obtaining clearance from Institutional ethics committee, medical records of patients who underwent open posterolateral thoracotomy between January 2012 and December 2015 were reviewed. Data on perioperative variables, address, and contact number were collected from the patient records. All patients were mailed the Telugu translation of medical outcome study short form -36(MOS-SF-36) QOL questionnaire and were contacted telephonically to enquire about presence of CPTP and QOL. A univariate analysis was done to assess factors associated with CPTP and a multivariate logistic regression analysis was done subsequently to identify independent risk factors of CPTP. QOL indices were compared between those patients who suffered from CPTP and those who did not. Results: The prevalence of pain in our study was 40.86% (85/208). The factors implicated in the causation of CPTP were diabetes mellitus, preoperative pain, rib resection, and duration of chest tube drainage with odds ratio of 9.8, 2.6, 6.7, and 1.03, respectively. The health-related QOL showed poor scores in all domains in patients suffering from CPTP. Conclusion: The prevalence of CPTP was high. It significantly impacts health-related QOL.
Aims and Objectives: To validate the Parsonnet scoring model to predict mortality following adult... more Aims and Objectives: To validate the Parsonnet scoring model to predict mortality following adult cardiac surgery in Indian scenario. Materials and Methods: A total of 889 consecutive patients undergoing adult cardiac surgery between January 2010 and April 2011 were included in the study. The Parsonnet score was determined for each patient and its predictive ability for in-hospital mortality was evaluated. The validation of Parsonnet score was performed for the total data and separately for the subgroups coronary artery bypass grafting (CABG), valve surgery and combined procedures (CABG with valve surgery). The model calibration was performed using Hosmer-Lemeshow goodness of fit test and receiver operating characteristics (ROC) analysis for discrimination. Independent predictors of mortality were assessed from the variables used in the Parsonnet score by multivariate regression analysis. Results: The overall mortality was 6.3% (56 patients), 7.1% (34 patients) for CABG, 4.3% (16 patients) for valve surgery and 16.2% (6 patients) for combined procedures. The Hosmer-Lemeshow statistic was <0.05 for the total data and also within the subgroups suggesting that the predicted outcome using Parsonnet score did not match the observed outcome. The area under the ROC curve for the total data was 0.699 (95% confidence interval 0.62-0.77) and when tested separately, it was 0.73 (0.64-0.81) for CABG, 0.79 (0.63-0.92) for valve surgery (good discriminatory ability) and only 0.55 (0.26-0.83) for combined procedures. The independent predictors of mortality determined for the total data were low ejection fraction (odds ratio [OR]-1.7), preoperative intra-aortic balloon pump (OR-10.7), combined procedures (OR-5.1), dialysis dependency (OR-23.4), and re-operation (OR-9.4). Conclusions: The Parsonnet score yielded a good predictive value for valve surgeries, moderate predictive value for the total data and for CABG and poor predictive value for combined procedures.
Turkish journal of anaesthesiology and reanimation, Jun 24, 2021
Objective: Amino acids attenuate hypothermia during the perioperative period by increasing thermo... more Objective: Amino acids attenuate hypothermia during the perioperative period by increasing thermogenesis and stimulating energy consumption. Percutaneous nephrolithotomy (PCNL) induces profound hypothermia owing to the use of large volumes of irrigating fluids. The role of amino acids in this group of surgeries for hypothermia and shivering prevention has been evaluated in this study because there is no available literature of concern. Methods: This prospective randomised controlled trial was conducted in patients undergoing PCNL. Group A received amino acids at 60 mL h-1 an hour before surgery until the end of surgery. Group C received normal saline infusion. Perioperative nasopharyngeal temperature, haemodynamics, and postoperative shivering were recorded. Results: Although there was no significant difference in temperature in the intraoperative period, postoperative decrease in the temperature was less in the amino acid group. In the postoperative period, 2 patients in the amino acid group and 11 patients in the control group experienced shivering. Conclusion: Intravenous administration of amino acids attenuated postoperative hypothermia and reduced shivering in patients undergoing PCNL without any adverse effects.
Introduction: Local anaesthetics used in spinal anaesthesia have a limited duration of action. To... more Introduction: Local anaesthetics used in spinal anaesthesia have a limited duration of action. To prolong postoperative analgesia, adjuvants, mainly opioids, are used. As µ agonist drugs have side effects, other receptor agonists are considered. Nalbuphine is a safe and effective kappa agonist adjuvant. Aim: To compare the analgesic efficacy between fentanyl and nalbuphine adjuvants added to 3 mL of 0.5% intrathecal hyperbaric bupivacaine. Materials and Methods: This prospective, double-blind, comparative study was conducted in 60 patients of either sex belonging to the American Society of Anesthesiologists classes I and II aged 18–65 years undergoing lower limb surgery with entropy monitoring, randomly allocated into two groups. Group F (n = 30) received 0.5% hyperbaric bupivacaine (3 mL) + 25 µg (0.5 mL) fentanyl. Group N (n = 30) received 0.5% hyperbaric bupivacaine (3 ml) + 0.8 mg (0.5 mL) nalbuphine intrathecally. Hemodynamics, entropy, motor and sensory block characteristics, and complications were noted. Results: The nalbuphine group had a significantly longer two-segment regression time of sensory blockade and extended analgesia duration than the fentanyl group. Haemodynamics, entropy, time for onset of sensory and motor blockade and adverse effects were comparable in both groups. Conclusion: Nalbuphine prolongs sensory blockade and postoperative analgesia duration with minimal side effects and is a safe intrathecal adjuvant.
Therapeutic hypothermia has been advocated for neuroprotection in cardiac arrest-induced encephal... more Therapeutic hypothermia has been advocated for neuroprotection in cardiac arrest-induced encephalopathy, neonatal hypoxic-ischemic encephalopathy, traumatic brain injury, stroke, hepatic encephalopathy, and spinal cord injury, and as an adjunct to certain surgical procedures. In this review, we address physiological mechanism of hypothermia to mitigate neurological injury, the trials that have been performed for each of these indications, the strength of the evidence to support treatment with mild/moderate hypothermia. Evidence is strongest for prehospital cardiac arrest and neonatal hypoxicischemic encephalopathy. For traumatic brain injury, a recent meta-analysis suggests that cooling may increase the likelihood of a good outcome, but does not change mortality rates. For many of the other indications, such as stroke and spinal cord injury, trials are ongoing, but the data is insufficient to recommend routine use of hypothermia at this time. Although induced hypothermia appears to be a highly promising treatment, it should be emphasized that it is associated with a number of potentially serious side effects, which may negate some or all of its potential benefits. Prevention and/or early treatment of these complications are the key to successful use of hypothermia in clinical practice. various other disorders. The clinical use of TH is likely to increase in the near future; thus, anesthesiologists should have knowledge regarding the clinical applications of TH. The aim of this review was to describe the evidence for the use of therapeutic hypothermia in clinical practice. The impact of this therapy on outcome and methods for practice of hypothermia will be included in the review. A formal literature search was conducted using PubMed and Cochrane databases, to identify suitable original papers, meta-analysis and reviews. The search headings included the text words: Cerebral ischemia and hypothermia, therapeutic hypothermia and cardiac arrest and resuscitation, traumatic brain injury, neonatal hypoxic encephalopathy, cooling methods, outcome. The additional source of data was a hand search of references from relevant articles. Definition By definition, hypothermia is a body temperature less than 36 o C and it is divided into three stages: mild hypothermia, when the body temperature is between 35 o C-32 o C, moderate hypothermia when the body temperature is between 32 o C and 30 o C, and deep hypothermia when the body temperature is less than 30 o C. Therapeutic hypothermia is defined as a core temperature ≤ 35°C induced deliberately by artificial cooling, which is used to prevent or attenuate various forms of neurological injury [8]. Mechanisms underlying neuroprotective effects of Hypothermia Cerebral ischemia and subsequent reperfusion injury cause enormous biochemical, structural, and functional insults, which in a complex interrelated process leads to progressive cell destruction, neuronal apoptosis, and death [9]. Hypothermia has been shown to attenuate or ameliorate many of these deleterious temperaturesensitive mechanisms, thereby contributing to protection of the brain [10]. Many of the mechanisms underlying hypothermia's effects Dates:
Trends in Anaesthesia and Critical Care, Dec 1, 2017
Regional techniques at thoracic level for thoracotomy surgeries in infants are gaining wider acce... more Regional techniques at thoracic level for thoracotomy surgeries in infants are gaining wider acceptance. The principal focus is on preserving physiological stability and reducing postoperative pain and stress in these smaller individuals as they are more susceptible to impairment in pulmonary function. Knowledge about the drug pharmacokinetics, dynamics in this age group along with availablity of the adequate size equipment has revolutionised anesthesia in infants. This review focusses on the various techniques of regional anesthesia for thoracotomy in neonates and infants along with local anesthetics.
Prevalence of pulmonary thromboembolism (PTE) is very high when we compare the coronavirus diseas... more Prevalence of pulmonary thromboembolism (PTE) is very high when we compare the coronavirus disease 2019 positive patients with the other patients who are admitted in intensive care unit for other different infection. Thorough evaluation of the different causative factors for PTE should be better evaluated and prevention can be tried accordingly. Incidence of subclinical PTE that can give rise to future cardiac disease needs to be studied and plan of action can be done accordingly. Newer modalities of detecting PTE using non-invasive or simple invasive techniques need to be investigated to cope up in pandemic situation.
Sudden onset and de-novo Myasthenia gravis (MG) in the presence of systemic lupus erythematosus (... more Sudden onset and de-novo Myasthenia gravis (MG) in the presence of systemic lupus erythematosus (SLE) is a rare postpartum phenomenon and can easily misguide the treating physician. A known case of SLE, 4 days after an elective caesarean section, presented to the intensive care unit for weaning-off mechanical ventilation after being put on ventilatory support in the emergency room, following acute onset partial seizures. She was subsequently diagnosed to have new onset MG, treated for the condition and later successfully extubated.
The Journal of Clinical and Scientific Research, 2015
Background: Intravenous injection of lipid emulsion propofol induces a considerable degree of pai... more Background: Intravenous injection of lipid emulsion propofol induces a considerable degree of pain and the most preferred treatment suggested is pretreatment with intravenous lignocaine to alleviate such pain. The present study was designed to evaluate whether addition of metoclopramide to lignocaine offers any advantage over lignocaine alone as a pretreatment in prevention of pain following propofol injection. Methods: In this prospective, randomized, double-blind controlled study, 60 patients were randomized to receive either lignocaine (group A) or lignocaine with metoclopramide (group B) intravenously as a pretreatment before injection of propofol. Pain due to injection of propofol was assessed with a four point categorical verbal rating pain scale. The incidence and magnitude of pain was compared between the two groups. Results: There was no statistically significant difference in the perceived intensity of pain between the two groups at different time points after administrati...
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Papers by Padmaja Durga