Anesthesia Management in Intramural Uterine Myoma and Obesity Morbid Patients Who Underwent Myomectomy Perlaparatomy

Introduction. Obesity is a condition that increases the challenges in the surgical process. Obesity increases the risk of sleep apnea and affects anaesthetics. This case report aims to discuss the management of anaesthesia in a patient with morbid obesity. Case. Female, 26 years old, with intramural uterine myoma and morbid obesity, will undergo myomectomy per laparotomy with ASA II physical status, performed anaesthesia with general anaesthesia intubation technique using the anaesthetic agent Propofol 1-2.5 mg/kg titration until the patient falls asleep, fentanyl 1-2 mcg/kg, then the patient was intubated in a ramped position with sleep non-apnea. After it was confirmed that the ETT was entered, 30 mg of a muscle relaxant (atracurium) was added. The operation lasts 1 hour 30 minutes, with a bleeding 250 cc, hemodynamically stable. Conclusion. Morbid obesity has extraordinary implications for anaesthetic management. Various considerations for patients with morbid obesity are needed starting from the preoperative, intraoperative, to postoperative periods. Regional anaesthesia is preferred because the physiological function of unhealthy obese patients is impaired due to excess body weight. Selection of anaesthetic agent and calculation of drug dose is crucial to know because there is a change in the volume of distribution. The pharmacokinetics of most general anaesthetics are affected by the adipose tissue mass, produce a prolonged drug effect, and less predictable.

Supraclavicular block with Mepivacaine vs Ropivacaine, their impact on postoperative pain: a prospective randomised study

Background Supraclavicular block (SCB) with long-acting local anaesthetic is commonly used for surgical repair of distal radial fractures (DRF). Studies have shown a risk for rebound pain when the block fades. This randomised single-centre study aimed to compare pain and opioid consumption the first three days post-surgery between SCB-mepivacaine vs. SCB-ropivacaine, with general anaesthesia (GA) as control. Methods Patients (n = 90) with ASA physical status 1–3 were prospectively randomised to receive; SCB with mepivacine 1%, 25–30 ml (n = 30), SCB with ropivacaine 0.5%, 25–30 ml (n = 30) or GA (n = 30) with propofol/fentanyl/sevoflurane. Study objectives compared postoperative pain with Numeric Rating Scale (NRS) and sum postoperative Opioid Equivalent Consumption (OEC) during the first 3 days post-surgery between study-groups. Results The three groups showed significant differences in postoperative pain-profile. Mean NRS at 24 h was significantly lower for the SCB-mepivacaine group (p = 0.018). Further both median NRS and median OEC day 0 to 3 were significanly lower in the SCB-mepivacaine group as compared to the SCB-ropivacaine group during the first three days after surgery; pain NRS 1 (IQR 0.3–3.3) and 2.7 (IQR 1.3–4.2) (p = 0.017) and OEC 30 mg (IQR 10–80) and 85 mg (IQR 45–125) (p = 0.004), respectively. The GA-group was in between both in pain NRS and median sum OEC. Unplanned healthcare contacts were highest among SCB-ropivacaine patients (39.3%) vs. SCB-mepivacaine patients (0%) and GA-patients (3.4%). Conclusions The potential benefit of longer duration of analgesia, associated to a long-acting local anaesthetic agent, during the early postoperative course must be put in perspective of potential worse pain progression following block resolution. Trial registration NCT03749174 (clinicaltrials.gov, Nov 21, 2018, retrospectively registered).

Efficacy of Tobacco Leaves (Nicotiana tabacum) as Anaesthetic Agent on the Juveniles and Adults of African Catfish Clarias gariepinus (Burchell 1822)

Various fisheries and aquacultural practices such as handling, transportation, tagging and so on stress fish. To minimise the stress, fish should be anaesthetise using agents that is safe, cheap in cost and extraction, effective and readily available and which should induce anaesthesia and recovery within few minutes as compared to synthetic anaesthetics. This study investigated the efficacy of tobacco leaves extract (Nicotiana tabacum) as an anaesthetic agent on Clarias gariepinus juveniles and adults. Ethanolic extracts of the leaves at 50 mg L−1, 100 mg L−1, 150 mg L−1 and 200 mg L−1 were used to anaesthetise juveniles and adults of the fish in order to vary the effects of increasing concentrations on the fish. Least induction time in juveniles was 166.72 ±7.15s recorded in 200 mg L−1, while highest induction time of 476.32 ±3.29s was in 50 mg L−1. In adult, least induction time was 440.99 ±2.42s in 200 mg L−1 concentration, and highest was 916.75 ±6.65s in 50.00 mg L−1. Highest and lowest recovery times in juveniles were 1078.68 ±19.80s and 751.21 ±7.65s in 200 mg L−1 and 50.00 mg L−1 respectively. In adult, least recovery time was 361.83 ±5.14s in 50.00 mg L−1, while 200.00 mg L−1 produced the highest recovery time at 548.45 ±7.78s. 200 mg L−1 concentration of tobacco extract was the effective concentration, as it induces anaesthesia within 3 minutes and recovery within 9 minutes with no mortality. These high induction and recovery times may be due to scalessness and well vascularised skin of the fish and its high body lipid content which make nicotine to diffuse faster in and out of the body. 200.00 mg L−1 ethanolic extracts of tobacco leaves could be used to anaesthetise fish as it is safe, low cost in terms of purchase and extraction, readily available, biodegradable (without residual effect), eco-friendly and efficient. It can serve as an alternative to expensive, toxic, scarce MS-222 or clove oil in fisheries and aquaculture.

Private Practitioners Knowledge of Local Anaesthetic Systemic Toxicity (LAST)

BACKGROUND Local anaesthetics (LAs) by definition are drugs that reversibly block the transmission of a nerve impulse, causing reversible absence of pain sensations without affecting consciousness. As a complication of local anaesthetic administration, a condition called as local anaesthetic systemic toxicity (LAST) can occur which affects central nervous system (CNS) and cardiovascular system (CVS). Local anaesthetic systemic toxicity is a very serious condition that can cause death. In LAST, blood levels of anaesthetic agent exceed the maximum dose, usually as a result of multiple injections or an accidental injection into a vein. The main objective of this survey was to assess the knowledge of LAST among private practitioners and to spread awareness about this common but often neglected complication of local anaesthetic administration. METHODS A survey was conducted with a questionnaire comprising of 15 questions for 251 private practitioners (registered in Indian Dental Association, Gurugram). The survey was mailed to the participants and the response was collected through online mode only. Using Excel program, the results were organized in graphs and tables, and presented as descriptive statistics. RESULTS Of the 251 surveys sent online, 151 were completed, with a survey completion rate of 60 %. On an average, only 39.9 % of the participating dentists had adequate knowledge of local anaesthetic systemic toxicity. Based on the survey, only 3.3 % of participating dentists knew how to use lipid treatment and 55.6 % had no idea about lipid treatment. CONCLUSIONS If LAST occurs, the key is to recognize it immediately and institute appropriate management. Based on the survey, there is a need to create awareness about local anaesthetic systemic toxicity and its management among dentists. KEY WORDS Local Anaesthesia, Last, Complication, Toxicity, Overdose

Feasibility, safety, and economic consequences of using minimal flow anaesthesia by Maquet FLOW-i equipped with automated gas control

Low fresh gas flow rates are recommended because of their benefits, however, its use is limited due to associated risks. The main purpose of this study was to investigate whether 300 mL of fresh gas flow that practised with automated gas control mode is applicable and safe. The second aim is to show that automated mode can provide economic benefits. Sixty hepatectomy cases who suitable criterias were included to cohort study in three groups as prospective, sequential, observational. An operating room were allocated only for this study. 300 mL fresh gas flow with automated mode (groupA3), 600 mL fresh gas flow with automated mode (groupA6) and, 600 mL fresh gas flow with manually (groupM6) was applied. Patients’ respiratory, hemodynamic parameters (safety), number of setting changes, O2 concentration in the flowmeter that maintained FiO2:0.4 during the low flow anaesthesia (feasibility) and comsumption data of anaesthetic agent and CO2 absorber (economical) were collected and compared. p < 0.05 was accepted as statistical significance level. No significant differences were detected between the groups in terms of demographic data and duration of operation. Safety datas (hemodynamic, respiratory, and tissue perfusion parameters) were within normal limits in all patients. O2 concentration in the flowmeter that maintained FiO2:0.4 was statistically higher in groupA3 (92%) than other groups (p < 0.001) but it was still within applicable limits (below the 100%). Number of setting changes was statistically higher in groupM6 than other groups (p < 0.001). The anaesthetic agent consumption was statistically less in groupA3 (p = 0.018). We performed fresh gas flow of 300 mL by automated mode without deviating from the safety limits and reduced the consumption of anaesthetic agent. We were able to maintain FiO2:0.4 in hepatectomies without much setting changes, and we think that the automated mode is better in terms of ease of practise.

Severe Encephalatrophy and Related Disorders From Long-Term Ketamine Abuse: A Case Report and Literature Review

Ketamine is a glutamate N-methyl D-aspartate receptor antagonist and an anaesthetic agent that has been effectively used to treat depression. However, ketamine has also been increasingly used for recreational purposes. The dissociative side-effects of ketamine use, such as hallucinations, are the reason for abuse. Additionally, long-term ketamine abuse has been highly associated with liver-gallbladder and urinary symptoms. The present study reports the case of a 28-year-old young male adult with an 8-year history of daily inhalation of ketamine. We investigated the association between ketamine abuse and the mechanism of its adverse effects, particularly encephalatrophy, and attempted to find a link between these disorders. These results would help us to better understand ketamine usage, ketamine abuse effects and the addictive mechanism. To the best of our knowledge, the present case is the first report of severe brain atrophy related to ketamine abuse. Details of the patient are presented and the mechanism of the encephalatropy-associated ketamine abuse is discussed. Furthermore, organ dysfunction following chronic ketamine abuse may indicate that the side effects are the result of comprehensive action on multiple regions in the brain.

Anaesthetic Effects of Propofol, Ketamine and their Combination (Ketofol) as Total Intravenous Anaesthesia (TIVA) in Pigs

Background: Endotracheal intubation for inhalation anaesthesia in pigs is not considered a good anaesthetic method as it is technically difficult because of oral anatomy and the presence of excess tissues in the oropharyngeal region. Moreover, the major limitation of inhalation anaesthesia is that it requires the use of a cumbersome and costly anaesthetic machine, including a suitable breathing system and vaporizer and is the exposure of operating-room personnel to the pollution in the ambient air. Therefore, the present study was undertaken to evaluate the effect of propofol, ketamine and their combination ‘Ketofol’ as a TIVA in pigs. Methods: The study was conducted in eighteen piglets of either sex. The piglets were randomly divided into three groups with six animals in each group. All the three groups were premedicated with Atropine sulphate @ 0.04mg/kg body weight and Xylazine Hydrochloride @ 1mg/kg body weight I.M. and Medazolam @ 0.5mg/kg body weight I.M. with minimum forcible restraint as pre-anaesthetic. In group-I, propofol @ 5mg/kg body weight, in group-II, ketamine @ 5mg/kg body weight and in group-III, ketofol @ 4mg/kg body weight was administered intravenously for induction after 15 minutes of pre-anaesthetic administration. Surgical anaesthesia was maintained for 90 minutes in all three groups viz. group-I, group-II and group-III with propofol @ 2.5mg/kg, ketamine @ 2.5mg/kg and ketofol @ 2mg/kg body weight respectively by intermittent bolus injection (IBI) technique. Clinical and cardiopulmonary profiles were evaluated before administration of the anaesthetic agent (0 minutes) then at 15, 30, 60 and 90 minutes during and after administration of anaesthetic agents to evaluate their anaesthetic effect. Result: The study revealed that induction time (IT), duration of analgesia (DOA), duration of recumbency (DOR) and recovery time (RT) interval showed better result in the combination of ketamine and propofol group as compared to propofol and ketamine-induced individual group. The temperature and respiration rate was significantly decreased in all the groups at 30 minutes during TIVA whereas heart rate was significantly increased in all the groups at 15 minutes. The combination of ketamine and propofol group showed a consistent diastolic pressure and systolic pressure during the entire period of anaesthesia. The SPO2 in the ketamine-induced group showed a significant decrease (P less than 0.01) as compared to the propofol and ketofol group. It was concluded that the anaesthetic drug combinations resulted in smooth and uneventful induction with mild cardiopulmonary depressions and rapid recovery.

Effect of meloxicam coadministration on the anaesthetic potency of thiopental sodium in a chick model

Few studies have dealt with thiopental sodium-induced anaesthetic action and the effect of combining meloxicam (a high plasma protein-bound) in 10–15 day old chicks. First, the analgesic median effective dose (ED50) was determined as 35.85 mg/kg, IM by up-and-down routine, while the hypnotic ED50 value was 34.40 mg/kg, IM in the chick model. A thiopental sodium injection (18, 36 and 72 mg/kg, IM) produces a significant dose-responsive hypnotic effect in chicks, determined by the beginning of the lack of a righting reflex, duration and recovery time. Thiopental sodium and meloxicam (72 and 1 mg/kg, IM) in combination shortened the beginning of hypnosis, and significantly extended its duration, with a significant increase in recovery time from the hypnotic effect when compared to the group receiving only thiopental sodium. The same combination also elicited a significant increase in the analgesic percentage and efficacy, and significant increase in the voltage current estimated via using electrical stimulation to induce the ache feeling. No significant changes were found in the concentrations of serum glutamate pyruvate trans-aminase (GPT), glutamate oxalo-acetate trans-aminase (GOT) with body temperature between the two groups, with the exception of a significant change in respiratory rate. The outcomes of this study support the prospect of using thiopental sodium as an anaesthetic agent for veterinary surgical procedures in the chicks, in combination with meloxicam, to produce worthy, consistent, and proficient anaesthesia.