Comparison of Prophylactic Intravenous Magnesium Sulfate with Tramadol for Postspinal Shivering in Elective Cesarean Section: A Placebo Controlled Randomized Double-blind Pilot Study

Background and Aims:

Cesarean sections are performed mostly under spinal anesthesia. Shivering is one of the distressing complications. The aim of the study was to compare the efficacy of intravenous (i.v) magnesium sulfate and tramadol with placebo (normal saline) on postspinal shivering in elective cesarean section when used as prophylaxis.

Methods:

One hundred and thirty-five pregnant women between 18 and 35 years age, belonging to the American Society of Anesthesiologists’ physical Status II, undergoing elective cesarean section under spinal anesthesia were enrolled into the study. Patients belonging to Group C (control group, n = 45) received isotonic saline 100 mL i.v, Group T (tramadol group, n = 45) received tramadol 0.5 mg/kg in 100 mL isotonic saline i.v, whereas those in Group M (magnesium sulfate group, n = 45) received magnesium sulfate 30 mg/kg in 100 mL isotonic saline i.v after administering spinal anesthesia. Incidence and grades of shivering were noted. Data were analyzed using one-way ANOVA test and Chi-square test.

Results:

The incidence of shivering in Group C, Group T, and Group M were 67.5%, 43.9%, and 39%, respectively. The incidence of shivering in Group M and Group T was significantly low when compared to Group C (P = 0.008; P = 0.026), whereas there was no statistically significant difference between Groups T and M (P = 0.654).

Conclusion:

Magnesium sulfate and tramadol significantly reduce the incidence of shivering compared to placebo when used as prophylaxis in pregnant women undergoing cesarean section under spinal anesthesia. Magnesium sulfate reduces the severity of the shivering.

EO technique provides better mask seal than the EC clamp technique during single handed mask holding by novices in anaesthetised and paralysed patients

Background and Aims:

Bag mask ventilation (BMV) allows for oxygenation and ventilation of patients until a definitive airway is secured and when definitive airway is difficult/impossible. This study hypothesised that the EO (thumb and index finger form a O shape around the mask) technique of mask holding provides better mask seal with the novices compared to the classic EC clamp technique (thumb and index finger form a C shape around the mask).

Methods:

Sixty patients participated in this double blinded, prospective, crossover study. The patients were randomly allocated to either EC or EO group. After adequate anaesthesia and neuromuscular blockade, a novice (experience of less than five attempts at BMV) held the mask with preferred hand with the allotted technique, while the ventilator provided five breaths at set pressure control of 15 cm H₂O with one second each for inspiration and expiration. After recording the exhaled tidal volume (primary objective) for each breath for five consecutive breaths, the study was repeated with the other technique. Secondary outcome variables were minute ventilation, audible mask and epigastric leak.

Results:

The tidal volume and minute ventilation were significantly better with EO technique compared with the EC technique (P = 0.001, a tidal volume difference of 46 mL and P = 0.001, a minute volume difference of 0.51 L).

Conclusion:

The EO technique provides better mask seal (superior tidal volumes) than the conventional EC technique during single-handed mask holding performed by novices in the absence of other factors contributing to difficulty in mask ventilation.

Critical appraisal of published literature

With a large output of medical literature coming out every year, it is impossible for readers to read every article. Critical appraisal of scientific literature is an important skill to be mastered not only by academic medical professionals but also by those involved in clinical practice. Before incorporating changes into the management of their patients, a thorough evaluation of the current or published literature is an important step in clinical practice. It is necessary for assessing the published literature for its scientific validity and generalizability to the specific patient community and reader's work environment. Simple steps have been provided by Consolidated Standard for Reporting Trial statements, Scottish Intercollegiate Guidelines Network and several other resources which if implemented may help the reader to avoid reading flawed literature and prevent the incorporation of biased or untrustworthy information into our practice.

E-O technique is superior to E-C technique in manikins during single person bag mask ventilation performed by novices

Conventional E-C technique of mask holding is unreliable during single person bag mask ventilation (BMV) due mainly to leak around the mask and inexperience of the persons. In this manikin study, conventional E-C technique was compared with E-O technique during single person BMV both with experienced (n = 50) and novice (n = 50) volunteers. The E-O technique involved encircling the mask neck with the web between thumb and index finger while the other digits provided chin lift. Two independent observers recorded the chest expansion as 1 (nil), 2 (minimal), 3 (moderate) and 4 (good). For analysis ideal and average chest expansion were clubbed as acceptable. E-C technique in experienced volunteers showed acceptable results in 49 (31 + 18) occasions, while with novices acceptable is 39 (17 + 22). With E-O technique, expansion was acceptable in 47 (38 + 9) experienced volunteers, and acceptable in 46 (32 + 14) novices. (P = 0.003). In cross over analysis for experienced volunteers, similar chest expansion was obtained on 30 occasions with both techniques, E-C better than E-O on 8 and E-O better than E-C on 12 occasions. Novices had comparable results on 17 occasions, E-C better than E-O on 8 and E-O better than E-C on 25 occasions (P = 0.016). The conventionally taught E-C technique of single person BMV provides acceptable chest expansion on most occasions with experienced operators than novices. Novices should use E-O technique as the first choice for single person BMV. Both techniques may be used interchangeably when one fails.

Cosmetics and health: usage, perceptions and awareness

Objectives: Cosmetics are a multi-billion dollar industry today. The present study was designed with an objective to know the extent, purpose, type and awareness for cosmetic in people's daily life in Surat city. Materials & Methods: The study was conducted among 500 randomly selected people from the Surat city through convenience sampling. All the participants were interviewed personally, using structured questionnaire. The whole study was conducted from December, to March, 2008. Results; Around 73% of the population used cosmetics for protection purpose, while only 37% used it for attraction and 19% for fashion. Only 31% checked whether cosmetic they used were tested on animals or not. 89% of the people are concerned about the brands of the cosmetic and advertisement is an important source in the selection of the cosmetics. People still prefer ayurvedic products which comprise of 44% of the total population. Only 9% of the people use the expired products suggesting that people are aware that expired products cannot be used. 77% of the people are aware about the side effects of the cosmetics. Conclusion: Overall prevalence of cosmetic product use is increasing among both males and females. Though, associated increase in awareness regarding safe use of the same was not present widely. The use of other cosmetic services like skin specialist visits, contact lenses usage is also increasing slowly. DOI: http://dx.doi.org/10.3329/bjms.v12i4.13330 Bangladesh Journal of Medical Science Vol. 12 No. 04 October ’13 Page 392-397

Agonal gasps of cardiac arrest victim can aid in confirming tracheal intubation using Umesh's intubation detector

Several patients of cardiac arrest may be found in a state of agonal gasps that are of insufficient tidal volume and are not considered as a sign of life. However, this volume is sufficient enough to cause appreciable inflation and deflation of the reservoir bag of Umesh's intubation detector (UID) as evidenced in all 12 victims of cardiac arrest with gasping efforts in this study. Therefore, we conclude that the agonal gasps during cardiac arrest can reliably be used to confirm tracheal intubation using the UID device.

Anesthetic management of a child with corrected transposition of great vessels undergoing non-cardiac surgery

We describe the successful anesthetic management of a 14-year-old child, a corrected case of transposition of great vessels in childhood and presently with residual atrial septal defect, peripheral cyanosis, and neurological deficit of lower limb presented for tendoachillis lengthening.

Validation of the new intubation detector device: a manikin study

This study was done to validate the utility of Umesh's intubation detector in detection of tracheal or oesophageal intubation in manikin using volunteers with different levels of experience in tracheal intubation (including novices). The Sim Man II, (Laerdal Medical AS, Norway) manikin was used. Two cuffed tracheal tubes of size 6.5 mm ID were used. One was passed into the trachea and the other into oesophagus. The device was connected to one of the two tubes as per randomisation table and three high quality chest compressions were performed. Each volunteer participated in the study twice. Their opinion regarding the tube position (in trachea or oesophagus or could not determine) was noted. A total of 50 volunteers participated in the study. Eleven of them had not observed intubation (novice), 29 had either only observed or had experience of <10 tracheal intubations (less experienced) and 10 had experience of >10 intubations or >1 year experience in tracheal intubation (experienced). Out of a total 100 performances, 99 were correctly identified. On one instance, a tube placed in trachea was incorrectly interpreted to be in the oesophagus by a novice. Umesh's intubation detector helps in rapid and reliable confirmation of tracheal intubation in manikin irrespective of the experience level of the assessor in tracheal intubation.

Arterial line for monitoring SpO2 in patients with ischemic peripheries

Monitoring the oxygenation status of patients with poor peripheral perfusion or ischemic peripheries is challenging in view of unreliable or unrecordable pulse oximeter data. In this article we describe a very simple and innovative technique of using the arterial line for reliable recording of arterial oxygen saturation (SpO(2)) in such patients. We conclude that the arterial line can be used as an extension of the artery and SpO(2) may be reliably measured using the arterial line in such patients as long as the blood in the arterial tubing is pulsatile and a good contact is ensured between the arterial tubing and the sensor of the pulse oximeter.

Solutions to some of the existing problems with breathing equipment type

Despite the stringent guidelines laid down by the American Society of Anesthesiologists for equipment checks, there are occasional reports of problems related to the equipment used to administer anesthesia. In this article, we discuss two important, albeit rare, problems associated with breathing equipment that have been reported in the literature. The rarity of these problems in itself may hinder early diagnosis because anesthesiologists do not usually consider these problems to be the cause of an ongoing patient morbidity. The first problem discussed here is the presence of a foreign body within the breathing system used to administer anesthesia. The second problem discussed is a kink in the breathing circuits that can precipitate life-threatening problems if it is not detected early enough.

Tight reservoir bag: the bag itself may be the culprit

Numerous possibilities exist which may cause obstruction to ventilation under anesthesia resulting in a tight reservoir bag with low compliance. We report an interesting case where a reservoir bag twisted around its own neck and resulted in a tight bag situation. The neck portion of the reservoir bag would be hidden from the view of anesthesiologists in head and neck surgery and hence it is easier to miss early recognition of the twist. We caution all anesthesiologists using the disposable modified Jackson-Rees breathing system to be aware of such an eventuality. We also urge the manufacturer to consider strengthening the neck of the reservoir bag by improving the quality of the material used for its construction.

Leak in the breathing circuit: CO2 absorber and human error

A couple of reports in literature have mentioned CO2 absorbers to be the cause for breathing circuit leak during anesthesia. Defective canister, failure to close the absorber chamber and overfilling of the chamber with sodalime were the problems in these reports. Among these, the last two are reports of human error resulting in problems. We report a case where despite taking precautions in this regard, we experienced a significant leak in the system due to a problem with the CO2 absorber, secondary to human error.

Immediate postoperative airway obstruction secondary to airway edema following tumor excision from the neck

A 46-year-old woman was scheduled for excision of a malignant peripheral nerve sheath tumor from the neck. The tumor had caused deviation of the trachea to the left and partial obstruction of the superior vena cava. Her upper airway at laryngoscopy after induction of anesthesia was normal. During tumor resection there were transient phases characterized by the complete disappearance of the peripheral oxygen saturation (Sp(O2)) and radial artery tracings. At the end of the operation, the trachea was extubated after ensuring adequate antagonization of neuromuscular blockade. However, immediately post-extubation, she showed signs of acute airway obstruction that necessitated reintubation of the trachea. Laryngoscopy revealed significant edema of the upper airway and vocal cords, requiring a smaller size tracheal tube. Many reports suggest the development of significant airway edema 24 h after such surgery. Our report highlights the fact that this can happen in the immediate postoperative period also. Some authors suggest that, in such surgery, extubation should routinely be done over pediatric tube exchangers. Routine leak testing and direct laryngoscopic/fiberoptic evaluation of the upper airway prior to extubation may also help. While our report reaffirms these points, it also stresses the importance of intraoperative monitoring for the compression of the great vessels, which may serve as a useful indicator of the early development of airway edema.

Anesthetic management of a patient with prosthetic heart valve for non-cardiac surgery: A case report

Background

Patients with prosthetic heart valves are a challenge to any anesthesiologist due to the risk of infective endocarditis, bleeding and thrombosis.

Case presentation

We present anesthetic management of a 58-year-old Indian lady with a prosthetic (mechanical) heart valve who underwent hemireplacement arthroplasty.

Conclusion

Patients with prosthetic heart valves, especially those with the mechanical valves are prone for thrombosis and resultant complications if anticoagulation is not maintained properly. However, when they are scheduled for major surgery, they can be best managed by normalising the coagulation profile immediately prior to surgery and restarting the anticoagulation as early as possible.