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2015| May | Volume 59 | Issue 5
Online since
May 12, 2015
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CLINICAL INVESTIGATIONS
Anaesthesia for awake craniotomy: A retrospective study of 54 cases
Navdeep Sokhal, Girija Prasad Rath, Arvind Chaturvedi, Hari Hara Dash, Parmod Kumar Bithal, P Sarat Chandra
May 2015, 59(5):300-305
DOI
:10.4103/0019-5049.156878
PMID
:26019355
Background
and Aims:
The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre.
Methods:
Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded.
Results:
Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (
P
> 0.05). There was less incidence of intraoperative seizures in patients who received propofol (
P
= 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1-14 days) and mean hospital stay was 7.0 ± 5.0 day (3-30 days).
Conclusions:
'Conscious sedation' was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure.
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Comparative evaluation of propofol, sevoflurane and desflurane for neuroanaesthesia: A prospective randomised study in patients undergoing elective supratentorial craniotomy
Priska Bastola, Hemant Bhagat, Jyotsna Wig
May 2015, 59(5):287-294
DOI
:10.4103/0019-5049.156868
PMID
:26019353
Background and Aims:
Both inhalational and intravenous anaesthetic agents are being used for neuroanaesthesia. Clinical trials comparing "propofol and sevoflurane" and "desflurane and sevoflurane" have been published. However, the comparison of all the three anaesthetics in neurosurgical patients has not been done. A randomised clinical study was carried out comparing propofol, sevoflurane and desflurane to find the ideal neuroanaesthetic agent.
Methods:
A total of 75 adult patients undergoing elective craniotomy for supratentorial tumours were included in the study. The patients were induced with morphine 0.1 mg/kg and thiopentone 4-6 mg/kg. Neuromuscular blockade was facilitated with vecuronium. The patients were randomised to receive propofol, sevoflurane or desflurane along with nitrous oxide in oxygen for maintenance of anaesthesia. The neuromuscular blockade was reversed following the surgery once the patients opened eyes or responded to verbal commands. The three anaesthetics were compared for their effects on haemodynamics, brain relaxation and emergence characteristics.
Results:
The mean arterial blood pressure during anaesthesia was comparable among the groups. The patients receiving sevoflurane had faster heart rates intraoperatively when compared to desflurane (
P
< 0.05). The brain relaxation scores at various intraoperative time frames were comparable among the three groups (
P
> 0.05). The time to response to verbal commands were significantly prolonged with use of sevoflurane (8.0 ± 2.9 min) when compared to propofol (5.3 ± 2.9 min) and desflurane (5.2 ± 2.6 min) (
P
= 0.003). However, the time to emergence and the number of patients who had early emergence (<15 min) were comparable among the groups (
P
> 0.05). The quality of emergence (coughing and emergence agitation), as well as postoperative complications, were also comparable among the three groups.
Conclusions:
All the three anaesthetic agents-propofol, sevoflurane and desflurane appear comparable and acceptable with regard to their clinical profile during anaesthesia in patients undergoing elective supratentorial surgeries.
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Estimation of effect-site concentration of propofol for laryngeal mask airway insertion using fentanyl or morphine as adjuvant
MV Gopinath, M Ravishankar, Kusha Nag, VR Hemanth Kumar, J Velraj, S Parthasarathy
May 2015, 59(5):295-299
DOI
:10.4103/0019-5049.156874
PMID
:26019354
Background and Aims:
Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides jaw relaxation and suppression of upper airway reflexes. Propofol can provide these conditions especially when combined with narcotics. This study had been designed to find out the effect-site concentration (EC
50
) of propofol using target controlled infusion (TCI) when fentanyl or morphine is added as an adjuvant.
Methods:
Patients satisfying inclusion criteria were divided into fentanyl and morphine groups. Intravenous glycopyrrolate 0.2 mg was given 15 min before induction. Patients were given either intravenous fentanyl (1 μg/kg) or morphine (0.1 mg/kg) before propofol infusion depending on the group. Patients in either groups were induced by continuous infusion of propofol at an EC of 6 μg/mL by TCI with Schneider pharmacokinetic model. The LMA supreme of appropriate size was inserted 1 min after achieving target concentration. Patient movement at LMA insertion or within 1 min of insertion was classified as failure. For subsequent patients, the target EC was increased/decreased depending on previous patients' response. Dixons up and down method was used to determine the EC
50.
The EC
50
is defined as the mean of crossover midpoints in each pair of failure to success.
Results:
The EC
50
of propofol in the fentanyl group for LMA insertion was 5.95 ± 0.6 μg/ml and morphine group was 5.75 ± 0.8 μg/ml. No significant difference in insertion conditions was noticed between the two groups (
P
= 0.3).
Conclusion:
We conclude that there was no significant difference in propofol EC
50
for insertion of LMA and insertion conditions were similar when fentanyl or morphine was used as an adjuvant drug.
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REVIEW ARTICLE
Perils of paediatric anaesthesia and novel molecular approaches: An evidence-based review
Sukhminder Jit Singh Bajwa, Smriti Anand, Hemant Gupta
May 2015, 59(5):272-281
DOI
:10.4103/0019-5049.156865
PMID
:26019351
Evolution of anaesthesia has been largely helped by progress of evidence-based medicine. In spite of many advancements in anaesthesia techniques and availability of newer and safer drugs, much more needs to be explored scientifically for the development of anaesthesia. Over the last few years, the notion that the actions of the anaesthesiologist have only immediate or short-term consequences has largely been challenged. Evidences accumulated in the recent years have shown that anaesthesia exposure may have long-term consequences particularly in the extremes of ages. However, most of the studies conducted so far are
in vitro
or animal studies, the results of which have been extrapolated to humans. There have been confounding evidences linking anaesthesia exposure in the developing brain with poor neurocognitive outcome. The results of animal studies and human retrospective studies have raised concern over the potential detrimental effects of general anaesthetics on the developing brain. The purpose of this review is to highlight the long-term perils of anaesthesia in the very young and the potential of improving anaesthesia delivery with the novel molecular approaches.
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BRIEF COMMUNICATIONS
Glycine induced acute transient postoperative visual loss
Anita Pramod, Shanmugam Rajagopal, V Padmanabha Iyer, Hanuman Srinivasa Murthy
May 2015, 59(5):318-319
DOI
:10.4103/0019-5049.156890
PMID
:26019359
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EDITORIAL
Fluid resuscitation in severe sepsis and septic shock: Shifting goalposts
Pradeep Kumar Bhatia, Ghansham Biyani
May 2015, 59(5):269-271
DOI
:10.4103/0019-5049.156863
PMID
:26019350
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3,588
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LETTERS TO EDITOR
Anaesthetic management of a patient with Jarcho-Levin syndrome
Neena Jain, Pooja Mathur, Priya Verma, Arvind Khare
May 2015, 59(5):322-323
DOI
:10.4103/0019-5049.156892
PMID
:26019361
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1,754
281
The successful use of sugammadex and uneventful recovery from general anaesthesia in a patient with myotonic dystrophy
Usha Gurunathan, Gemma Duncan
May 2015, 59(5):325-326
DOI
:10.4103/0019-5049.156894
PMID
:26019363
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1,630
362
Central anticholinergic syndrome in a neonate operated for tracheoesophageal fistula
S Suresh Kumar, Nikhil Jain, Smita Prakash, Mridula Pawar
May 2015, 59(5):330-331
DOI
:10.4103/0019-5049.156901
PMID
:26019366
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1
1,690
543
Self-knotting of a nasogastric tube passed through i-gel™
Shaloo Garg, Mukul Chandra Kapoor
May 2015, 59(5):331-332
DOI
:10.4103/0019-5049.156902
PMID
:26019367
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1,347
276
BRIEF COMMUNICATIONS
Dexmedetomidine for anaesthetic management of phaeochromocytoma in a child with von Hippel-Lindau type 2 syndrome
Raylene Dias, Nandini Dave, Madhu Garasia
May 2015, 59(5):319-321
DOI
:10.4103/0019-5049.156891
PMID
:26019360
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1,641
382
Myxoedema coma in adults: Experience from a tertiary referral hospital intensive care unit
Tejaswini Arunachala Murthy, Pradeep Rangappa, IPR Jacob, Rajeshwari Janakiraman, Karthik Rao
May 2015, 59(5):315-317
DOI
:10.4103/0019-5049.156889
PMID
:26019358
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4,134
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CASE REPORT
Dyskeratosis congenita induced cirrhosis for liver transplantation-perioperative management
Anshuman Singh, VK Pandey, Manish Tandon, CK Pandey
May 2015, 59(5):312-314
DOI
:10.4103/0019-5049.156888
PMID
:26019357
Dyskeratosis congenita (DC) is an inherited disorder with progressive multisystem involvement. End stage liver disease (ESLD) in patients with DC is rare. We describe the perioperative management of a patient with DC induced ESLD and severe hepatopulmonary syndrome for living donor liver transplantation.
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CLINICAL INVESTIGATIONS
Attenuation of the haemodynamic responses to tracheal intubation with gabapentin, fentanyl and a combination of both: A randomised controlled trial
Satyen Parida, Niyaz Channanath Ashraf, Jibin Sam Mathew, Sandeep Kumar Mishra, Ashok Shankar Badhe
May 2015, 59(5):306-311
DOI
:10.4103/0019-5049.156885
PMID
:26019356
Background
and
Aims:
We conducted a prospective, randomised, double-blind, controlled clinical trial to examine (1) whether a single preoperative dose of 800 mg gabapentin would be as effective as 2 μg/kg of intravenous (IV) fentanyl in blunting the haemodynamic response to tracheal intubation and (2) whether a combination of both would be more effective in this regard.
Methods:
Seventy-five patients (American Society of Anaesthesiologists physical status I), aged 20-50 years were allocated into one of three groups: 2 μg/kg IV fentanyl, 800 mg oral gabapentin or a combination of both. Gabapentin was administered 2 h and fentanyl 5 min before induction of anaesthesia, which was achieved with 5 mg/kg thiopentone, and tracheal intubation facilitated with 0.1 mg/kg vecuronium. Laryngoscopy lasting a maximum of 30 s was attempted 3 min after administration of the induction agents. Serial values of mean arterial pressure (MAP) and heart rate (HR) were compared among the three groups and with the respective preinduction measurements.
Results
: Patients receiving gabapentin 800 mg alone showed remarkable increases in HR and MAP in response to tracheal intubation (
P
< 0.05). The increases were similar for the other two regimens. These haemodynamic changes were lesser in patients receiving fentanyl and the combination of gabapentin and fentanyl.
Conclusion:
Oral gabapentin does not produce significant reduction in laryngoscopy and tracheal intubation induced sympathetic responses as compared to IV fentanyl or the combination of gabapentin and fentanyl.
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A comparative study of pharmacological myocardial protection between sevoflurane and desflurane at anaesthestic doses in patients undergoing off pump coronary artery bypass grafting surgery
Umesh Sivanna, Shreedhar Joshi, Balaji Babu, AM Jagadeesh
May 2015, 59(5):282-286
DOI
:10.4103/0019-5049.156867
PMID
:26019352
Background
and
Aims:
Perioperative myocardial ischaemia (PMI) is one of the known complications during off pump coronary artery bypass (OPCAB) surgeries. The length of hospital stay is considerably prolonged in patients with PMI. Myocardial protection is an area which is being widely researched currently to prevent or reduce the incidence of PMI. Over the last decade it has become clear that volatile anaesthetic agents are protective in the setting of PMI and reperfusion. Hence, we planned to study the effect of two different volatile anaesthetics as myocardial protective agents in OPCAB surgery.
Methods:
A total of 40 patients were enrolled for the study; Group A (sevoflurane,
n
= 20) and Group B (desflurane,
n
= 20). All patients had a baseline measurement of Trop-T, creatine phosphokinase-MB (CPKMB) and myocardial performance index (MPI) pre-operatively, which was repeated 4 h after the surgery. Chi-square/Fisher test was used to find the significance of the differences between the two agents.
Results:
Patients were comparable in demographic, baseline, biochemical and echo criteria. Post-operative CPKMB levels (desflurane - 30.85 ± 2.69 u/L; sevoflurane - 29.05 ± 5.26 u/L,
P
= 0.7) and number of Trop-T positive patients (Sevoflurane - 9; desflurane - 6,
P
≥ 0.05) were comparable. Post-operative MPI indicated decreased left ventricular function in sevoflurane group as compared to desflurane group (
P
≤ 0.03).
Conclusion:
Desflurane exerts better cardioprotective effect than sevoflurane as indicated by better MPI in OPCAB surgeries.
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COMMENTS ON PUBLISHED ARTICLES
Coiling of guidewire in the internal jugular vein: Putting some caveats
Mohan Chandra Mandal, Anirban Karmakar, Sekhar Ranjan Basu
May 2015, 59(5):334-334
DOI
:10.4103/0019-5049.156907
PMID
:26019369
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1,193
322
LETTERS TO EDITOR
A patient with VACTERL association for caesarean delivery
Kamalakkannan Thulasidoss, Aparna Duraisamy, Murugesh Babu
May 2015, 59(5):326-328
DOI
:10.4103/0019-5049.156896
PMID
:26019364
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2,557
306
Massive hydrothorax following supracostal percutaneous nephrolithotomy
Smita Prakash, Pooja Virmani, Pramod Gupta, Mridula Pawar
May 2015, 59(5):328-330
DOI
:10.4103/0019-5049.156898
PMID
:26019365
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1,365
258
Cisatracurium degradation: Intravenous fluid warmer the culprit?
Rashid M Khan, Naresh Kaul, Raj Gopal Nair
May 2015, 59(5):323-325
DOI
:10.4103/0019-5049.156893
PMID
:26019362
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