Comparison of stress and burnout among anesthesia and surgical residents in a tertiary care teaching hospital in North India

Objective:

The residents undergoing training at hospitals in our country face challenges in terms of infrastructure and high workload with undefined working hours. The aim of the study was to compare the stress and burnout levels in trainee doctors doing residency in surgical fields and anesthesia at a tertiary care academic center in North India.

Materials and Methods:

A comparative, observational study was conducted in a tertiary care teaching hospital in North India. After Ethics Committee approval, 200 residents (100 each from surgical branches and anesthesia) were required to fill a questionnaire with information about age, sex, year of residency, marital status, and the Perceived Stress Scale-10, and Burnout Clinical Subtype Questionnaire-12. Burnout and perceived stress were compared between residents of anesthesia and surgical specialties.

Results:

Residents of both surgical and anesthesia branches scored high in perceived stress, namely 21 and 18, respectively. The score was significantly higher in surgical residents (P = 0.03) and increased progressively with the year of residency. The majority of residents (90% surgical, 80% anesthesia) felt that they were being overloaded with work. However, only 20%–30% of respondents felt that there was lack of development of individual skills and still fewer (<10%) reported giving up in view of difficulties.

Conclusion:

There is high level of stress and overload dimension of burnout among the residents of anesthesia and surgical branches at our tertiary care academic institution and the surgical residents score marginally higher than anesthesia residents.

Efficacy of Low-dose Dexamethasone for Preventing Postoperative Nausea and Vomiting following Strabismus Repair in Children

We studied the efficacy of a range of doses of dexamethasone for prevention of postoperative nausea and vomiting following strabismus repair in children in a hospital-based, prospective, double-blinded, randomized, placebo-controlled trial.

Two hundred and ten children were randomized to receive either dexamethasone in one of four dosages: 50 μg/kg (Group 1), 100 μg/kg (Group 2), 200 μg/kg (Group 3) and 250 μg/kg (Group 4) or normal saline (Group 5) prior to corrective surgery for strabismus. Anaesthesia was standardized and included nitrous oxide, pethidine, intubation and the use of muscle relaxant and reversal with neostigmine. Postoperative nausea and vomiting were evaluated in epochs of 0-2 hours, 2-6 hours and 6-24 hours after surgery. Parent satisfaction was assessed 24 hours after surgery and the operated eye was examined for wound infection and delayed healing one week later.

Dexamethasone was effective in preventing nausea and vomiting after strabismus repair: 57.1% children in Group 1, 42.9% in Group 2, 52.4% in Group 3, and 59.5% in Group 4 were free from postoperative nausea and vomiting compared with 7.1% in placebo group. The lowest dose of 50 μg/kg was as efficacious as the higher dosages of dexamethasone during the 24 hours studied. Of the children who developed postoperative nausea and vomiting, those who received dexamethasone had significantly fewer episodes than those in the placebo group.

We conclude that dexamethasone 50 μg/kg is effective for the prevention of postoperative nausea and vomiting following strabismus repair in children.

Performance of target-controlled infusion of propofol using two different pharmacokinetic models in open heart surgery - a randomised controlled study

We compared the performance of a propofol target-controlled infusion (TCI) using Marsh versus PGIMER models in patients undergoing open heart surgery, in terms of measured plasma levels of propofol and objective pharmacodynamic effect.

Methods:

Twenty-three, ASA II/III adult patients aged 18-65 years and scheduled for elective open heart surgery received Marsh or PGIMER (Postgraduate Institute of Medical Education and Research) pharmacokinetic models of TCI for the induction and maintenance of anaesthesia with propofol in a randomized, active-controlled, non-inferiority trial. The plasma levels of propofol were measured at specified time points before, during and after bypass.

Results:

The performances of both the models were similar, as determined by the error (%) in maintaining the target plasma concentrations: MDPE of -5.0 (-12.0, 5.0) in the PGIMER group vs -6.4 (-7.7 to 0.5) in the Marsh group and MDAPE of 9.1 (5, 15) in the PGIMER group vs 8 (6.7, 10.1) in the Marsh group. These values indicate that both models over-predicted the plasma propofol concentration.

Conclusions:

The new pharmacokinetic model based on data from Indian patients is comparable in performance to the commercially available Marsh pharmacokinetic model.

Knowledge, attitude and practice of pediatric critical care nurses towards pain: survey in a developing country setting

BACKGROUND

Nurses' knowledge, sensitivity and attitudes about pain in children and its management affect their response and therefore management of pediatric pain. Children in critical care units undergo more painful procedures than those in general wards.

AIMS

To study the knowledge, attitude and practice of nursing personnel catering to critically ill children in a developing country.

SETTINGS AND DESIGN

Prospective questionnaire-based survey.

MATERIALS AND METHODS

The survey was carried out in a tertiary care teaching hospital on nursing personnel in three pediatric/neonatal intensive care units. The domains studied were: i. Training and experience, ii. Knowledge of pediatric pain, iii. Individual attitude towards pain in children, iv. Personal practice(s) for pain alleviation, v. Pain assessment, and vi. Non-pharmacological measures adopted.

STATISTICAL ANALYSIS

Descriptive statistics and logistic regression.

RESULTS

Of the 81 nursing personnel working in the three critical care units, 56 (69.1%) responded to the questionnaire. Only one-third of them had received formal training in pediatric nursing. Fifty percent of the respondents felt that infants perceive less pain than adults. Training in pediatric nursing was a significant contributing factor in the domain of knowledge (P=0.03). Restraint and distraction were the common modalities employed to facilitate painful procedures. Scientific approaches like eutectic mixture of local anesthetic and the judicious use of sedatives were not adopted routinely. Observing a child's face and posture were widely used parameters to assess pain (83%). None of the three critical care areas used a scoring system to assess pain.

CONCLUSIONS

There are several lacunae in the knowledge and practice of nurses in developing countries which need to be improved by training.

Unilateral common peroneal nerve palsy following renal transplantation: a case report of tacrolimus neurotoxicity

Neurologic complications are not uncommon in renal transplant recipients. Acute femoral neuropathy, lumbosacral plexopathy, and sciatic neuropathy have been reported after kidney transplantation probably due to perioperative nerve compression and ischemia. To the best of our knowledge, common peroneal nerve (CPN) palsy has not been described in the early postoperative period following renal transplantation. Also, mononeuropathy due to tacrolimus (TAC) therapy has not been described so far. We report a case of isolated CPN palsy presenting as unilateral foot drop following renal transplantation and that improved only after replacing TAC with cyclosporine.

Magnesium Sulphate for Treatment of Tetanus in Adults

There are reports that suggest that magnesium sulphate alone may control muscle spasms thereby avoiding sedation and mechanical ventilation in tetanus, but this has not been confirmed. We examined the efficacy and safety of intravenous magnesium sulphate for control of rigidity and spasms in adults with tetanus.

A prospective clinical study of intravenous magnesium sulphate was carried out over a period of two years in a tertiary care teaching hospital. In addition to human tetanus immunoglobulin and parenteral antibiotics, patients with tetanus received magnesium sulphate 70 mg/kg intravenously followed by infusion. The infusion was increased by 0.5 g/hour every six hours until cessation of spasms or abolishment of patellar tendon jerk. The primary outcome measure was efficacy determined by control of spasms. Secondary outcomes included frequency of autonomic instability, duration of ventilatory support, hospital stay and mortality.

Thirty-three patients were enrolled. At presentation, the incidence of severity of tetanus was as follows: Grade I: 5 (15%), Grade II: 13 (39%), Grade III: 14 (42%) and Grade IV: 1 (3%). Rigidity and mild spasms were controlled with magnesium therapy alone in six patients; all were Grades I or II. Additional sedatives were required in severe forms of tetanus. The average duration of ventilatory support was 18.3±16.0 days and the overall mortality was 22.9%. Asymptomatic hypocalcaemia was a universal finding.

Magnesium sulphate therapy alone may not be efficacious for the treatment of severe tetanus.

A single dose of preoperative gabapentin for pain reduction and requirement of morphine after total mastectomy and axillary dissection: randomized placebo-controlled double-blind trial

BACKGROUND

Gabapentin has been recently found to be useful for reducing acute postoperative pain when administered preoperatively. Although various dose regimens have been tried in different surgical settings, the minimum effective dose is not established.

AIMS

We aimed to evaluate the analgesic efficacy of single low dose gabapentin in patients undergoing total mastectomy and axillary dissection.

SETTINGS AND DESIGN

Prospective randomized placebo-controlled double-blind trial in a tertiary care teaching hospital.

MATERIALS AND METHODS

Fifty women scheduled for total mastectomy and axillary dissection were randomized to receive either gabapentin 600 mg or placebo orally 1 h preoperatively. The intraoperative and postoperative management was standardized. Postoperative pain was assessed at rest and on movement for 12 h using the numerical rating scale (NRS). Morphine was administered if NRS exceeded 30. Primary outcome measure was total morphine consumption.

STATISTICAL ANALYSIS

The morphine consumption was compared using independent t test while pain and sedation scores were analyzed using Mann-Whitney U test.

RESULTS

Forty-six patients completed the trial. The postoperative morphine consumption was significantly less (5.8 +/- 4.2 vs. 11.0 +/- 3.4 mg; P 0.001) and the median [IQR] time to first analgesic was significantly longer (90 [37.5-120] vs. 0 [0-90] min; P 0.001) in the gabapentin group than in the placebo group. The incidence of side effects was similar in the two groups.

CONCLUSIONS

A single low dose of 600 mg gabapentin administered 1 h prior to surgery produced effective and significant postoperative analgesia after total mastectomy and axillary dissection without significant side effects.

Propofol requirement titrated to bispectral index: a comparison between hypothermic and normothermic cardiopulmonary bypass

Though propofol requirement is expected to decrease during cardiopulmonary bypass (CPB), a few studies have failed to demonstrate this. The factors affecting pharmacokinetics of propofol and, therefore, the requirement, are different during hypothermic and normothermic CPB. We evaluated and compared the requirement of propofol during hypothermic and normothermic CPB. Fifty adult patients scheduled for elective cardiac surgery on CPB were recruited and randomly allocated into hypothermic CPB (28–300 C) (Group H) and normothermic CPB (35–370 C) (Group N) groups. Patients were induced and maintained with propofol titrated to maintain a target bispectral index (BIS) of 50 ± 10. Propofol requirement (mean ± SD) was similar in normothermic and hypothermic groups, both before CPB (4.9 ± 1.5 mg.kg−1hr−1 in Group N, 4.6 ± 1.5 mg.kg−1hr−1 in Group H) and after cessation of bypass (p > 0.05) (4.6 ± 1.8 mg.kg−1hr−1 in Group N and 4.3 ± 1.7 mg.kg−1hr−1 in Group H). CPB significantly reduced (p < 0.001) propofol requirements in both arms of the study (Group N: 2.9 ± 1.4 mg.kg−1hr−1and Group H: 1.3 ± 0.7 mg.kg−1hr−1). This reduction was more pronounced in the hypothermic group (p < 0.001). The BIS (median ± inter quartile range) remained constant during normothermic CPB (50 ± 8.8), but declined significantly during hypothermic CPB (41 ± 5.6) despite decreased usage of propofol during hypothermia. No patient had recall of intra-operative events. CPB decreases the magnitude of propofol requirements and the effect of hypothermic CPB is significantly more than that of normothermic CPB.

Efficacy of orally disintegrating ondansetron in preventing postoperative nausea and vomiting after laparoscopic cholecystectomy: a randomised, double-blind placebo controlled study

Peri-operative prophylactic anti-emetics are commonly used parenterally. Orally disintegrating ondansetron is efficacious during chemotherapy. Therefore, we aimed to study the efficacy of orally disintegrating ondansetron for postoperative nausea and vomiting. In a randomised, double-blind, placebo controlled trial on 109 patients scheduled for laparoscopic cholecystectomy, oral ondansetron was compared to intravenous ondansetron and placebo. The anaesthetic technique was standardised. Mean time (SD) to tolerating oral intake was delayed in the placebo group to 366.1 (77.6) min compared to oral 322.9 (63.7) min and intravenous 322.4 (65.2) min groups. This is corroborated by a higher incidence of nausea and vomiting in the control group during the first 6 h postoperatively (control 44.4%, oral 17.7%, intravenous 18.2%). There was no significant difference between oral and intravenous groups. In conclusion, orally disintegrating ondansetron was as efficacious as intravenous ondansetron in the peri-operative phase and may be a viable option for prophylaxis of emesis in day care surgery.

Comparison of closed loop vs. manual administration of propofol using the Bispectral index in cardiac surgery

BACKGROUND

In recent years, electroencephalographic indices of anaesthetic depth have facilitated automated anaesthesia delivery systems. Such closed-loop control of anaesthesia has been described in various surgical settings in ASA I-II patients (1-4), but not in open heart surgery characterized by haemodynamic instability and higher risk of intra-operative awareness. Therefore, a newly developed closed-loop anaesthesia delivery system (CLADS) to regulate propofol infusion by the Bispectral index (BIS) was compared with manual control during open heart surgery.

METHODS

Forty-four adult ASA II-III patients undergoing elective cardiac surgery under cardiopulmonary bypass were enrolled. The study participants were randomized to two groups: the CLADS group received propofol delivered by the CLADS, while in the manual group, propofol delivery was adjusted manually. The depth of anaesthesia was titrated to a target BIS of 50 in both the groups.

RESULTS

During induction, the CLADS group required lower doses of propofol (P<0.001), resulting in lesser overshoots of BIS (P<0.001) and mean arterial blood pressure (P=0.004). Subsequently, BIS was maintained within +/- 10 of the target for a significantly longer time in the CLADS group (P=0.01). The parameters of performance assessment, median absolute performance error (P=0.01), wobble (P=0.04) and divergence (P<0.001), were all significantly better in the CLADS group. Haemodynamic stability was better in the CLADS group and the requirement of phenylephrine in the pre-cardiopulmonary bypass period as well as the cumulative dose of phenylephrine used were significantly higher in the manual group.

CONCLUSION

The automated delivery of propofol using CLADS was safe, efficient and performed better than manual administration in open heart surgery.

Acute respiratory failure due to hypokalaemic muscular paralysis from renal tubular acidosis

We report a case of hypokalaemic quadriplegia with acute respiratory failure and life-threatening cardiac arrhythmias in a 26-year-old woman who was diagnosed to have distal renal tubular acidosis. She had persistent metabolic acidosis with severe hypokalaemia and required mechanical ventilation and potassium replacement. The anaesthetic implications of renal tubular acidosis are also discussed.

Anaesthetic considerations in Kartagener's syndrome -- a case report

Kartagener's syndrome is a rare disorder characterized by the triad of situs inversus, including dextrocardia, bronchiectasis and paranasal sinusitis. We report the anaesthetic management of a patient with Kartagener's syndrome and postrenal transplant immunosuppression, presenting for repair of uterovaginal prolapse. Combined spinal epidural anaesthesia was administered to this patient. The anaesthetic considerations of this rare disorder and the relative advantages of the regional technique over general anaesthesia in this situation are discussed.

Comparison of induction and recovery characteristics of intravenous midazolam and thiopentone in paediatric halothane general anaesthesia

Fifty children were randomized for induction with 0.3 mg kg(-1) midazolam or 5 mg kg(-1) thiopentone. Efficacy, safety, recovery time, amnesic effect, tolerability and recovery characteristics were compared. Midazolam required longer for induction and recovery from anaesthesia. The safety profile was similar with both drugs.

CONCLUSION

Midazolam is efficacious and safe for the induction of anaesthesia in children. Its action is comparable with thiopentone and may be an alternative to it.

Assessment and management of pain in infants

Infants, including newborn babies, experience pain similarly and probably more intensely than older children and adults. They are also at risk of adverse long term effects on behaviour and development, through inadequate attention towards pain relief in early life. However, the issue of analgesia in young babies has been largely neglected in most clinical settings, despite subjecting them to painful diagnostic and therapeutic procedures. Several therapeutic and preventive strategies, including systemic and local pharmacological and non-pharmacological interventions, are reported to be effective in relieving pain in infants. A judicious application of these interventions, backed by awareness and sensitivity to pain perception, on the part of the caregivers is likely to yield the best results. This article is a review of the mechanisms of pain perception, objective assessment, and management strategies of pain in infants.