AWAKENING CHARACTERISTICS AND RECOVERY OF COGNITIVE FUNCTION IN PATIENTS UNDERGOING SHORT SURGICAL PROCEDURES: COMPARISON BETWEEN DESFLURANE AND PROPOFOL

Objectives: Early awakening and recovery of the cognitive function improves post-operative outcome and early discharge of the patients. Desflurane and Propofol offer rapid emergence from anesthesia. We compared the awakening and recovery of cognitive function between these two agents. Methods: A total of 50 patients aged 30–60 years belonging to ASA 1 and 2 were studied. In both the groups baseline, Mini Mental State Examination (MMSE) score was recorded and were induced with Target controlled infusion (TCI) of Propofol to achieve plasma site concentration (Cp) of 6 mcg/ml. Group P continued with TCI Propofol Cp 3 mcg ml-1 and in group D, TCI was stopped and started Desflurane 6% end tidal concentration followed by Desflurane 3%. Hemodynamic variables were noted and after stopping the agent, time to eye open, squeeze hands, removal of laryngeal mask airway, state name, and modified Aldrete score were noted. MMSE score was recorded 1, 6, and 24 h postoperatively. Results: Awakening time was significantly shorter in duration in Desflurane group compared to Propofol. The mean time to eye open in the Propofol group was 10.41±2:31 min and Desflurane group was 06.21±01.42 min (***p=0.000). There was an increase in the mean MMSE score postoperatively at 6 h and 24 h interval when compared to the baseline within the groups. However, there was no difference in recovery of cognitive function between the two groups. Conclusion: The use of inhalational agent Desflurane provided shorter awakening time than intravenous Propofol in short surgical procedures but the recovery of cognitive function was comparable. There were no significant side effects.

Efficacy of Oral Clonidine as Premedication on Intraoperative Bleeding and Consumption of Inhalational Agent in Patients Undergoing Functional Endoscopic Sinus Surgery

Aim: To study the efficacy of oral clonidine on intraoperative bleeding and consumption of inhalational agent in patients undergoing FESS under general anesthesia. Study Design: Prospective, comparative observational study. Place and Duration of Study: Department of Anesthesiology, AVBRH, from June 2020 to May 2021. Methodology: A total of 30 patients fulfilling inclusion criteria scheduled for FESS were randomly allocated into 2 groups of 15 each; GROUP C (Clonidine group, n=15) who received tab clonidine 5 mcg/kg, 90 minutes before surgery and GROUP M (Multivitamin group, n=15) who received multivitamin tablet. Mean ± standard deviation (SD) or absolute values were used to indicate data; comparison of qualitative data were done using Chi-square test and Fisher’s exact test and quantitative variables using the student ‘t’ Test. P value < 0.05 was taken as statistically significant. Results: Bleeding was considerably less in the group C [1.65 ± 0.4] as compared to group M [2.20 ± 0.6] and is statistically significant [ P value = 0.006]. The mean MAC value (%) of sevoflurane consumption is lesser in the group C [1.25 ±0.25] than the group M [1.30 ±0.20] but not statistically significant (P value = 0.55). The mean dose (microgram) of fentanyl requirement was more in group M [ 120 ±20] than the group C [100 ± 25] and this was statistically significant (P value = 0.02). Conclusion: Oral Clonidine can be used as an excellent premedication and provides cost effective method to attain controlled hypotension as there is lesser requirement of costly inhalational agent and other analgesic drugs. Also, it maintains better hemodynamic stability with fewer side effects.

Is Greater Than 0.5 MAC Inhalational Agent Use Post-Bypass Related to Need for Inotropic and/or Vasoconstrictor Support?

Background and Aims: We hypothesized that maintaining a patient on moderate–high doses of potent inhalational agent for greater than 30 min during the post-bypass period would be an independent predictor of initiation and usage of either inotropic and/or vasopressor infusions. Setting and Design: This study is a retrospective design and approved by the institutional review board. The setting was a single-center, academic tertiary care hospital in Detroit, Michigan. Materials and Methods: Three-hundred, ninety-seven elective cardiac surgery patients were identified for chart review. Electronic medical records were reviewed to collect demographics and perioperative data. Statistics used include a propensity score regression adjusted analysis utilizing logistic regression models and a multivariable model. Results: A propensity score regression adjusted analysis was performed and then applied in both univariate and multivariate logistic regression models with a p value of <0.05 reaching statistical significance. Fifty-six percent of the participants had an exposure of greater than 30 min of a minimum alveolar concentration of isoflurane greater than 0.5 (ETISO ≥ 0.5MAC, 30 min) in the post-bypass period. After adjusting for propensity score, this was found to be a significant predictor of inotrope and/or vasoconstrictor use post-bypass (OR 2.49, 95% CI 1.15–5.38, p = 0.021). In the multivariate model, pulmonary hypertension (OR 5.9; 95% CI 1.33–26.28; p = 0.02), Euroscore II (2.73; 95% CI 1.35–5.5; p = 0.005), and cardiopulmonary bypass hours (OR 1.86; 95% CI 1.02–3.4; p = 0.042) emerged as significant. Conclusions: This study showed that an ETISO ≥ 0.5MAC, 30 min exposure during the immediate post-bypass period during elective cardiac surgery was an independent predictor of a patient being started on inotrope or vasoconstrictor infusions. Further research should consider a prospective design and examine depth of anesthesia during the post-bypass period.

'Green-gional' anesthesia: the non-polluting benefits of regional anesthesia to decrease greenhouse gases and attenuate climate change

Volatile halogenated gases and nitrous oxide used as part of a balanced general anesthetic may contribute to global warming. By avoiding volatile inhalational agent use, regional anesthesia may reduce greenhouse gas emissions and help prevent global warming. We present a theoretical calculation of the potential benefits and a real-life example of how much regional anesthesia may reduce greenhouse gas emissions.

Central anticholinergic syndrome following general anaesthesia: prevention and treatment with galantamine

Prolonged emergence, excitation and shivering after general anaesthesia are well-known, though only in German-speaking countries they are considered to be forms of single central anticholinergic syndrome (CAS), while in others this term is not associated with general anaesthesia. In Russia the problem is augmented with lack of physostigmine — the first choice for CAS in Germany. We present our analysis of implementing galantamine instead of physostigmine for CAS prevention and management while administering this drug for decurarization. 130 patients undergoing general anaesthesia were divided into three groups depending on decurarization — group I (n = 54) without decurarization, in group II (n = 29) we used galantamine, in group III (n = 47) — neostigmine. In all the groups we assessed CAS incidence and its galantamine treatment effectiveness. Diagnostic criteria for CAS comatose form was unconsciousness 5 min later reaching inhalational agent zero end-expiratory concentration. Using the criteria we found CAS incidence in group I was 26,9%, in group II there were no cases of the syndrome, in group III the incidence was 14,9%. Thus, galantamine 0,3–0,4 mg · kg–1 (max 0,78 mg · kg–1) IV not only prevents CAS but is also effective in its treatment.

A comparative study between intraoperativelow-dose ketamine and dexmedetomidine, as an anaesthetic adjuvant in lumbar spine instrumentation surgery for the post-operative analgesic requirement

Background: Spinal instrumentation and fusion surgery presents the anaesthesiologist with multiple issues like intraoperative blood loss, hemodynamic changes, prolonged surgery etc, but the most probing aspect is analgesia. While both ketamine and dexmedetomidine as adjuvants have shown to decrease intraoperative anaesthetics and post operative analgesic consumption but there are no comparative studies. The primary aim of this study was comparison of post-operative analgesic requirements for 1st 24 hours after surgery when either of the drugs was used as adjuvants. Methods: Adult patients aged 18-60 years, of either sex, and ASA status I or II scheduled for elective lumbar spine instrumentation (of 2 or more spinal levels) surgery were enrolled for the study. Patients were randomised into one of the 3 treatment regimens ketamine/group K (0.5mg/kg bolus followed by 250 mcg/kg/h infusion), dexmedetomidine/ group D (0.5mcg/kg bolus followed by 0.5 mcg/kg/h infusion) or the placebo/ group S (saline/placebo). The study drugs were started after turning the patient prone. Data were recorded for intraoperative hemodynamics, anesthetic consumption (inhalational agent and opioids), emergence through RAS scale (Riker sedation agitation scale), PCA (patient controlled analgesia)-fentanyl use and VAS (visual analog scale) score in the 1st 24 hours after surgery. Appropriate statistical analysis was done. Results: A total of 42 patients (14 in each group) were enrolled. The total PCA fentanyl consumed in first 24 hours of surgery was maximum with the group-S (1366.6±382.6 mcg) in compared with group- D (1035.4±391.8 mcg) and group- K (1164.9±503.6 mcg) (P=0.13). The post extubation RAS score was lower in group-K (3.7±0.6) when compared with group-D (4±0.4) and group-S (4.5±0.9) (P=.009). Total intraoperative sevoflurane and fentanyl consumption showed no difference (P=0.19 and P=0.28). VAS score at rest was higher at baseline with group-S (P=0.009). The ICU stay was comparable (group-D: 1.4±0.5 d, group-K: 1.5±0.5 d, group-S: 1.9±0.5 d) among the groups. Hospital stay was also comparable (P=0.09). Conclusion: In patients undergoing lumbar instrumentation surgery, opioid consumption, VAS scores, PCA pump bad demands, inhalational agent consumption, hospital stay were comparable when either ketamine or dexmedetomidine was used as intraoperative anesthetic adjuvants.

Use of desflurane in neurosurgery: Cons

Desflurane is being projected nowadays as inhalational agent of choice in the repertoire of the modern day anaesthesiologists. Refinement of its pharmacologic properties from its predecessors has attracted the attention of clinicians towards this novel agent. However, within the realms of neurosurgical anaesthesiology, the widespread use of desflurane today should be, at best viewed with a bit of caution. Although a sizeable number of advantages of using desflurane exist, anaesthesiologists dealing with neurosurgical patients should be cognizant of its drawbacks.