Comparison of nasal and face mask ventilation in anaesthetised obese adults: A randomised controlled study

Background and Aims

The use of a face mask while inducing general anaesthesia (GA) in obese patients is often ineffective in providing adequate ventilation. Although nasal mask ventilation has demonstrated effectiveness for continuous positive airway pressure (CPAP) in obese patients with obstructive sleep apnoea (OSA), it has not yet been applied to the induction of anaesthesia. This study evaluated the efficacy of nasal mask ventilation against standard face mask ventilation in anaesthetised obese patients with body mass index (BMI)>25 kg/m2.

Methods

Ninety adult patients with BMI >25 kg/m2 were randomly assigned to receive either facemask (Group FM) or nasal-mask (Group NM) ventilation during induction of GA. Expired tidal volume (VtE), air leak, peak inspiratory pressure (PIP), plateau pressure (PPLAT), oxygen saturation (SpO2), and end-tidal carbon dioxide (EtCO2) were recorded for10 breaths, and their mean was analysed.

Results

The mean (standard deviation) VtE measured was not significantly higher in Group NM [455.98 (55.64) versus 436.90 (49.50) mL, P = 0.08, degree of freedom (df):88, mean difference (95% confidence interval [CI]) -19.08 (-41.14, 2.98) mL]. Mean air-leak [16.44 (22.16) versus 31.63 (21.56) mL, P = 0.001, df: 88, mean difference 95%CI: 15.19 (6.03,24.35)], mean PIP [14.79 (1.39) versus 19.94 (3.05) cmH2O, P = 0.001, df: 88, mean difference, 95%CI: 5.15 (4.16, 6.14)], and mean PPLAT [12.04 (1.21) versus 16.66 (2.56) cmH2O, P = 0.001, df: 88, mean difference 95% CI: 4.62 (3.78, 5.45)] were significantly lower in Group NM. EtCO2, SpO2, and haemodynamic measurements were similar between the two groups.

Conclusion

Nasal mask ventilation is an effective ventilation method and can be used as an alternative to face mask ventilation in anaesthetised obese adults with BMI>25 kg/m2.

Efficacy of Different Volumes of 0.2% Ropivacaine in Suprainguinal Fascia Iliaca Compartment Block for Multimodal Analgesia in Lower Limb Surgery

Background Ultrasound-guided (USG) suprainguinal fascia iliaca (SIFI) block is being used widely for post-operative analgesia in patients undergoing hip and femur surgeries. However, the optimal volume of local anesthetic required for SIFI block is not well defined. Thus, we compared different volumes of 0.2% ropivacaine in SIFI for post-operative pain relief in lower limb surgeries. Material and methods A total of 90 patients undergoing hip and femur surgeries were randomly allocated into three groups: A, B, and C, who received USG SIFI block with 20 mL, 30 mL, and 40 mL of 0.2% ropivacaine, respectively. Intravenous tramadol was used as rescue analgesia when the numeric rating scale (NRS) score exceeded 3. Time to first request of rescue analgesic was the primary outcome. NRS scores in the first 24 hours post-operatively, total amount of tramadol consumption in 24 hours, and patient satisfaction with pain management were secondary outcomes. Results The time to first request to rescue analgesic was significantly longer in group B and group C as compared to group A. NRS scores were significantly reduced in group B and group C than group A in the 24-hour post-operative period. Median 24-hour tramadol consumption was significantly less in group C as compared to group A and group B. Patient satisfaction with pain management was better with group B and group C as compared to group A. Conclusion In comparison to 20 mL of 0.2% ropivacaine, 30 mL and 40 mL of 0.2% ropivacaine in SIFI compartment block are more efficacious in reducing post-operative pain after hip and lower limb surgeries.

Prevalence of High-dose Antipsychotic Prescribing in Schizophrenia: A Clinical Audit in a Regional Queensland Mental Health Service

Background

Antipsychotic medication is widely recognized as a critical intervention in both acute and ongoing treatments of schizophrenia. Guidelines endorse the routine practice of monotherapy with antipsychotic medication at the minimum effective dose. Despite the recommendations, high-dose antipsychotic prescribing and polytherapy appear to be common practice.

Objective

The objective of this study was to determine the prevalence of high-dose antipsychotic prescribing in adult patients with schizophrenia in a regional Queensland hospital and to know if the prescribing practices are in keeping with the international guidelines and with the local policy introduced in December 2017.

Methods

This was a cross-sectional survey/clinical audit of 358 adult patients with schizophrenia open to the service in both community and inpatient settings. The individual prescribing practices of psychiatrists were also examined.

Results

A minority (15%) were prescribed high doses (high-dose single agent and high dose by polytherapy) and 20% were prescribed polytherapy (including high dose and within normal dose range).

Conclusion

Eighty-five percent of the patients with the diagnosis of schizophrenia open to the service were prescribed antipsychotic within the dose range. In this respect, prescribing was aligned with current evidence-based guidelines.

Role of handgrip strength testing in pre-anaesthetic check-up: A prospective cross-sectional study

Background and Aims

Frailty has been known to be associated with postoperative adverse events and longer hospital length of stay (LOS). Hand grip strength (HGS) is one of the parameters of measuring frailty. The aim of the study was to correlate preoperative handgrip strength and 30-day outcome of patients undergoing major abdominal surgery. It also aimed to evaluate the role of the standard preoperative variables like metabolic equivalents, revised cardiac risk index (RCRI), serum albumin, and serum creatinine along with their association with HGS testing in determining the postoperative outcome in surgical patients.

Material and Methods

This prospective observational study included 149 American Society of Anesthesiologists class III/IV patients presenting for major abdominal surgery. A mean of three measurements of dominant HGS using Camry hand dynamometer was measured. The patients were divided into groups: weak, normal, and strong depending on grip strength. Patients were followed for 30 days and postoperative outcome in terms of ventilatory support, admission to intensive care unit, cardiac complications, in-hospital mortality, and LOS were recorded. Observational data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann-Whitney Rank test. Associations between RCRI, serum albumin, and LOS with HGS were evaluated using logistic regression.

Results

The hospital LOS was significantly longer in patients with weak HGS (15.11 ± 11.03 days versus 10 ± 5.71 days, P = 0.001). Patients with weak HGS had significantly lower mean serum albumin levels compared to normal HGS (P = 0.0001) and a statistically significant RCRI score (P = 0.013).

Conclusion

HGS can be used as a preoperative test in predicting hospital LOS after major surgery.

Effect of add-on Gabapentin premedication on hemodynamic response to skull pin insertion

Background and Aims:

Material and Methods:

Results:

Conclusion:

Comparison of norepinephrine and phenylephrine infusions for maintenance of haemodynamics following subarachnoid block in lower segment caeserean section

Background and Aims:

Phenylephrine is the vasopressor of choice in spinal anaesthesia–induced maternal hypotension. However, it results in reflex bradycardia and decrease in cardiac output (CO), an effect that is perhaps less evident with the use of norepinephrine. We sought to evaluate the effect of phenylephrine and norepinephrine infusion on maternal systolic blood pressure (SBP), heart rate (HR), intraoperative nausea vomiting (IONV) and fatal Apgar scores.

Methods:

A randomised double-blind study was conducted on 200 American Society of Anesthesiologists (ASA) II–III parturients undergoing caesarean section under subarachnoid block (SAB) who were randomised to two groups A and B to receive variable rate, manually controlled infusions of phenylephrine and norepinephrine targeting maintenance of SBP to 100% of the baseline value. Maternal haemodynamics especially episodes of hypotension, IONV and vasopressor consumption were observed and recorded.

Results:

A statistically significant trend of lower SBP was observed during the first 6 min following intrathecal injection in group A (P value – 0.000). Though a greater number of parturients experienced ≥1 episode of hypotension in Group A vs Group B (13% vs 9%), the difference was, however, statistically insignificant. The incidence of bradycardia was higher in group A than in group B (16% vs 1%) and was found to be statistically significant (P < 0.05). The episodes of hypertension, IONV, maternal vasopressor consumption and neonatal Apgar score were comparable among both the groups.

Conclusion:

A dilute solution of norepinephrine infusion is comparably efficacious to the current gold standard vasopressor phenylephrine in maintaining blood pressure following spinal anaesthesia for caesarean delivery, with a significantly lower incidence of bradycardia.

Effects of ventilation mode type on intra-abdominal pressure and intra-operative blood loss in patients undergoing lumbar spine surgery: A randomised clinical study

Background and Aims:

The aim of the study was to evaluate the effect of mode of mechanical ventilation; pressure-controlled ventilation (PCV) vs. volume-controlled ventilation (VCV) on airway pressures, intra-abdominal pressure (IAP) and intra-operative surgical bleeding in patients undergoing lumbar spine surgery.

Methods:

This was a prospective, randomised study that included 50 American Society of Anesthesiologists class I and II patients undergoing lumbar spine surgery who were mechanically ventilated using PCV or VCV mode. The respiratory parameters (peak and plateau pressures) and IAP were measured after anaesthesia induction in supine position, 10 min after the patients were changed from supine to prone position, at the end of the surgery in prone position, and after the patients were changed from prone to supine position. The amount of intraoperative surgical bleeding was measured by objective and subjective methods.

Results:

The primary outcome was the amount of intraoperative surgical bleeding. It was significantly less in the PCV group than in the VCV group (137 ± 24.37 mL vs. 311 ± 66.98 mL) (P = 0.000). Similarly, on comparing other parameters like peak inspiratory pressures, plateaupressures and IAP, the patients in PCV group had significantly lower parameters than those in VCV group (P < 0.05). No harmful events were recorded.

Conclusion:

In patie,nts undergoing lumbar spine surgery, use of PCV mode decreased intraoperative surgical bleeding, which may be related to lower intraoperative respiratory pressures and IAP.

Comparison of intra-articular analgesia and femoral nerve block for postoperative pain relief in unilateral total knee arthroplasty: A randomized clinical study

Background and Aims:

Femoral nerve block (FNB) and intra-articular analgesia (IAA) are used for postoperative analgesia after total knee arthroplasty (TKA).

Aims and Objectives:

We aimed to determine the better technique among the two, with regard to duration and quality of postoperative analgesia along with 24-h rescue analgesic consumption. The functional recovery in the early postoperative period was also assessed.

Settings and Design:

This was a prospective double-blind study comprising 40 American Society of Anesthesiologists I–III patients undergoing elective TKA who were randomly assigned to two groups (n = 20).

Methodology:

In Group A, 20 mL ropivacaine 0.5%, containing dexmedetomidine (1 μg.kg ^{− 1}), was given by FNB, and in Group B, intra-articular administration of the same drug was done. Analgesic effect was evaluated by measuring the Visual Analog Scale (VAS) and duration of analgesia. Quadriceps muscle strength was noted.

Statistical Analysis:

Observation data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann–Whitney rank test.

Results:

The mean VAS on passive movement at the 2^nd, 6^th, and 16^th h postoperatively was 1.75 ± 0.44, 2.90 ± 0.72, and 2.75 ± 0.44 in Group A as compared to 2.25 ± 0.72, 4.30 ± 2.05, and 2.20 ± 0.77 in Group B (P = 0.026, 0.043, and 0.014, respectively). In Group A, the first request for analgesic (rescue analgesic) was at 637 ± 119 min and the total consumption of tramadol was 50.00 mg. In Group B, the first request for analgesic was at 404.44 ± 136 min, with a total dose of 63.89 mg. The Pvalue for the time of rescue analgesic was <0.001, while for total drug consumption, it was 0.018.

Conclusion:

We concluded that the duration and quality of analgesia (VAS) were significantly superior and rescue analgesic requirement less in patients who received FNB as compared to IAA.

Evaluation of Myocardial Injury using Standard Diagnostic Tools and Tissue Doppler Imaging in Blunt Trauma Chest

INTRODUCTION

Myocardial contusion is an entity in chest trauma which is difficult to diagnose. Current practice relies more on cardiac-specific biochemical markers and standard echocardiography, but no gold standard test exists. The application of Tissue Doppler imaging is yet unexplored.

AIM

The present study was designed to evaluate cardiac injury in patients with blunt trauma chest using conventional trans-thoracic echocardiography parameters and Tissue Doppler imaging.

MATERIALS AND METHODS

After ethical approval was taken from the Hospital and University and a written informed consent from all patients/attendants, this prospective study was conducted on a total of 30 patients in range of 15-60 years of age with blunt trauma chest. Patients with positive Trop-T and raised CPK (> 308 IU/L), raised CK-MB (> 24 IU/L) levels were suspected to have myocardial injury and were enrolled in the study. All patients fulfilling the inclusion criteria then underwent 2D-Echo and Tissue Doppler Imaging. Results of the observations were analysed using chi-square test.

RESULTS

Out of the total of 30 patients, 63.3% showed ECG changes suggestive of cardiac injury. A 76.7% patients suffered systolic dysfunction and 36.6% patients suffered diastolic dysfunction irrespective of ECG changes. On comparison of early filling velocity wave i.e., E wave (measured by transthoracic echocardiography) and tricuspid annular velocity Em wave (measured by tissue Doppler echocardiography) at tricuspid valve, we found statistically significant difference among two techniques. (p = 0.04).

CONCLUSION

Echocardiography is very sensitive parameter for evaluation of myocardial contusion. Tissue Doppler imaging provides additional and reliable information.

Evaluation of Cardiopulmonary Resuscitation (CPR) for Patient Outcomes and their Predictors

INTRODUCTION

Cardiac arrest continues to be a common cause of in-hospital deaths. Even small improvements in survival can translate into thousands of lives saved every year.

AIM

The aim of our prospective observational study was to elicit the outcomes and predictors of in-hospital cardiopulmonary resuscitation among adult patients.

SETTINGS AND DESIGN

All in-hospital adult patients (age >14) who suffered cardiac arrest & were attended by a Code Blue Team between 1(st) January 2012 & 30(th) April 2013 were part of the study.

MATERIALS AND METHODS

The cardiopulmonary resuscitation (CPR) was assessed in terms of: Response time, Presenting initial rhythm, Time to first defibrillation, Duration of CPR and Outcome (Return of spontaneous circulation (ROSC), Glasgow outcome scale (GOS) at discharge).

STATISTICAL ANALYSIS

Age, GOS and mean response time were analysed using t-test and ANOVA. Logistic regression was applied to determine the significance of the various factors in determining mortality.

RESULTS

ROSC was achieved in 44% of a total of 127 patients included in our study. Asystole/Pulseless electrical activity (PEA) was the most common presenting rhythm (87.5%). The survival to discharge was seen in 7.1% patients of whom only 3.9% patients had good neurological outcome. Regression and survival analysis depicted achievement of ROSC during CPR, absence of co-morbidities and shorter response time of code blue team as predictors of good outcome.

CONCLUSION

We found poor outcome of CPR after in-hospital cardiac arrest. This was mainly attributed to an initial presenting rhythm of Asystole/PEA in most cases and delayed response times.

Sports Induced Cardiac Arrest: A Case of Missed Rhabdomyolysis

Exercise induced rhabdomyolysis although uncommon, is well known in strenuous and exhaustive sports like marathons, cycling and wrestlers. But it is not known in Kabaddi players. We report a case of nearly fatal rhabdomyolysis which was missed during early resuscitation in emergency room and lead to cardiac arrest due to catastrophic metabolic acidosis and severe -hyperkalemia. After high quality cardiopulmonary resuscitation and return of spontaneous rhythm, emergency resuscitative exploratory laparotomy was performed for suspected bladder injury which was negative. He had remarkable recovery over 24 h following diagnosis and aggressive supportive management including peritoneal dialysis. Heat stroke and rhabdomyolysis should be suspected early in players playing strenuous sports in tropical countries even during winter. High degree of suspicion and early aggressive general support is the key to success for unusual clinical presentation of any such clinical entity.

Comparative efficacy of two different dosages of intrathecal magnesium sulphate supplementation in subarachnoid block

BACKGROUND

Spinal anaesthesia is the primary anaesthetic technique for many types of surgeries. Adjuncts to the local anaesthetics (LA) used in spinal anaesthesia can exhibit undesirable side-effects like respiratory depression, urinary retention, pruritis, haemodynamic instability and nausea and vomiting, limiting their use. Magnesium when used in therapeutic doses avoids all of these side-effects.

MATERIALS AND METHODS

We conducted a randomized double blind study on 90 patients, 30 in each group, scheduled for orthopaedic lower limb surgery under subarachnoid block. Group I: received bupivacaine (0.5%), 12.5 mg + 0.5 ml of preservative free 0.9% normal saline, Group II received bupivacaine (0.5%), 12.5 mg + 0.2 ml (50 mg) of preservative free 25 % magnesium sulphate + 0.3 ml of preservative free 0.9% normal saline Group III: received bupivacaine (0.5%) 12.5 mg + 0.3 ml (75 mg) of 25 % magnesium sulphate + 0.2 ml of preservative free 0.9% normal saline for subarachnoid block. The onset and duration of sensory block, the highest dermatomal level of sensory block, motor block, time to complete motor block recovery and duration of spinal anaesthesia were recorded.

STATISTICAL ANALYSIS

ANOVA was applied to determine the significance of difference between different groups. If p-value was significant then Turkey's Post Hoc Multicomparison test was applied. Values of p<0.05 were considered to be statistically significant.

RESULTS

The time of maximum sensory block, time of onset of motor block, duration of sensory block, duration of motor block and time of analgesia request were prolonged in patients given magnesium 50mg and 75mg along with local anaesthetic intrathecally.

CONCLUSION

N-methyl-D-aspartate (NMDA) receptor antagonist, magnesium when administered intrathecally along with local anaesthetics prolongs the duration of spinal analgesia without adverse effects.