Efficacy of dexmedetomidine in attenuating hemodynamic and airway responses during extubation: a randomized double-blind study

Background Tracheal extubation causes significant hemodynamic changes and airway irritation. During smooth extubation there is absence of straining, movement, coughing, breath holding, laryngospasm and minimal change in hemodynamic. Purpose of this study was to evaluate the efficacy of dexmedetomidine in attenuating hemodynamic and airway responses during extubation. Methodology Eighty patients receiving general anesthesia were included in this randomized double-blind study. Ten minutes before the end of anesthesia, Group D (Dexmedetomidine group) (n=40) received Inj. Dexmedetomidine 0.5mcg/kg and Group N (Normal Saline group) (n=40) received 10 ml normal saline over 10 mins. Heart rate and mean arterial pressure were recorded prior to the drug administration till 10 mins after extubation. The incidence of cough was monitored during extubation. Any possible side effects of study drugs were recorded. Results Age, gender, physical status, weight, duration of surgery, baseline heart rate and mean arterial pressure were comparable between the groups. There was statistically significant difference (p < 0.05) in heart rate and mean arterial pressure between the groups after 5 mins of study drug administration and then throughout the study period. Using four point scale for coughing during extubation, 10% of Group D and 50% of Group N had minimal cough, 22.5% of Group N and 2.5% of Group D had moderate cough. Conclusion Finding suggests that intravenous dexmedetomidine before extubation significantly attenuates hemodynamic and airway responses during extubation.

Fixed-dose versus height and weight-adjusted dose of intrathecal 0.5% hyperbaric bupivacaine in elective cesarean section: A comparative study

Background: Spinal anesthesia is the preferred anesthetic technique for cesarean deliveries. But there is a dosage dilemma regarding block to the desired level and preventing hypotension. We aim to study effects of fixed dose with height and weight-adjusted dose of intrathecal 0.5% hyperbaric bupivacaine during elective cesarean section. Methods: Eighty-eight singleton term parturients were enrolled and divided into two groups, Group FD (Fixed Dose) and CD (Calculated Dose) in this prospective, double-blind, randomized controlled trial. Group FD received 2.2 ml and CD received a height and weight adjusted calculated dose based on Harten's chart. Hemodynamic changes, onset time to sensory block to T6, maximum block in 20 minutes, and adverse effects were compared. Results: There was a significant reduction in median drug dosage of 11mg in FD versus 9 mg in CD group. The decrease in the MAP was less in group CD (14.5±2.98) mmHg compared to (17.6±4.66) mmHg in group FD (P= 0.03). The median onset time of spinal block to T6 in group FD of 2 minutes with IQR (2-3) was faster than Group CD 4 minutes with IQR (3-5). The spinal block extended above T4 in the larger number of parturients 23 (52 %) in Group FD than in three (6.8%) in group CD (p<0.05). Significantly larger number 20 (45.45 %) in group FD developed hypotension than seven (15.9 %) in Group CD. Bradycardia and vomiting were also found in group FD. Conclusions: This calculated dose provided the desired level of the spinal block and also restricted spinal block level with a distinct advantage of less hypotension.

Pediatric Lung isolation in a limited resource setup: a case report

Rationale: Pediatric lung isolation is a great challenge to an anesthesiologist. Despite various advances in techniques and equipment in lung isolation, most of the sophisticated devices are unavailable in remote setups. Blind techniques have been used, but they have a low success rate. Patient concerns: Here we report a case of a five year old male child who had cough and fever for one month. CT scan of chest revealed right sided empyema thoracis for which decortication was planned under general anaesthesia with one lung ventilation. Double lumen tube for this patient was not commercially available and we did not have a paediatric fiberoptic bronchoscope, which would fit inside the endotracheal tube necessary for the patient. Interventions: After anesthesia induction, an adult fiberoptic bronchoscope was used as an aid for insertion of bougie into the left mainstem bronchus followed by rail roading the endotracheal tube over the bougie for lung isolation. Outcomes: Surgery then proceeded in left lateral position with a right thoracotomy under a quiet surgical field. Conclusion: In case of unavailability of paediatric fiberoptic bronchoscope, an adult fiberoptic bronchoscope and a bougie can aid in successful lung isolation in paediatric patients.

Hemodynamic changes during orotracheal intubation using Airtraq video laryngoscope and direct laryngoscope: A randomized comparative study

Introduction: Direct laryngoscopy is associated with sympathetic stimulation and altered hemodynamics. A long intubation time may result in a greater in stress response. Alternative techniques using video laryngoscopes have been developed that do not require direct vocal cord visualization and may decrease the hemodynamic response. This study aimed to compare the difference between hemodynamic changes and intubation time with Airtraq video laryngoscope and conventionl Macintosh direct laryngoscope. Methods: A prospective randomized comparative study was conducted involving 100 adult patients who were undergoing elective surgeries under general anesthesia and endotracheal intubation. The patients were randomly assigned to group V (Video laryngoscope) or group D (Direct laryngoscope). In addition to the baseline vitals and vitals at various time intervals, intubation time was also recorded. We considered a difference in Heart Rate and Mean Arterial pressure of 20% to be clinically significant and statistical significance was p-value <0.05. Results: Significant difference was found in heart rates immediately after laryngoscopy (110.40 vs. 105.02 beats/minute; p<0.01) and 1 minute after intubation (109.30 vs. 106.20 beats/minute; p<0.01) with attenuation seen in video laryngoscopy group. Blood pressures were similar in both the groups at all times. Time for intubation was prolonged in video laryngoscopy group than that for direct laryngoscopy group (26.54 vs. 22.80 seconds; p<0.05). There were no adverse events associated with either of the techniques. Conclusions: The Airtraq video laryngoscopy resulted in lesser change in heart rate and longer intubation time. However, clinical impact of such a difference seemed to be insignificant.

Establishing pain service in Dharan, Nepal: overcoming the inertia

The author describes the initial days of establishing pain management services in the eastern part of Nepal.

Collection of abstracts of 20th SANCON 2019

This submission is a collection of abstracts of 20th SANCON 2019 for JSAN.

Combination of caudal epidural steroids with oral gabapentin for radicular low back pain: a prospective observational study

Introduction: The physical, socioeconomic and psychological burden of low back pain is enormous. The poor socioeconomic condition and geographical constrains confines people to limited health facilities. The objective of the study was to evaluate whether combination of caudal epidural steroids with local anaesthetics and gabapentin is effective for radicular low back pain in the rural Nepal setting. Methods: It was a prospective observational study including 300 patients with radicular low back pain done over a period of 6 months (13/4/2016 to 30/10/2016). All participants received caudal epidural steroid injection (6ml 2% Xylocaine with adrenaline plus Depomedroxy steroid 80mg plus 12 ml distilled water) and 200 mg gabapentin daily for three months. All patients were followed up for three months and were evaluated. Results: Mean age of presentation was 41.21 years (SD ± 11.02) with majority of farmers (42.31%). Mean Numerical Rating Scale at the baseline was 8.01(SD±1.00) and at the first follow up was 3.98 (SD±0.83) (p <0.001). Mean Oswestry Disability Index at baseline was7.85 (SD±0.98) and at the first follow up was 4.04 (SD±0.80) (p <0.001). Straight Leg Raising Test at baseline was less than 70° in 84.7% which improved to more than 70° in 87.9% of the patients (p-value <0.001). Conclusion: Caudal epidural steroids combined with gabapentin is safe, economical and technically less demanding. This treatment modality can be used with good outcomes in the rural areas with limited diagnostic and therapeutic facilities.

Adding moments to history of Anesthesia of Nepal: Truth or fiction?

This article describes about a person who might have served as anesthesia provider during 1930s at the Bir Hospital, Kathmandu, Nepal. However, concrete evidence of the person’s work as an anesthesia provider has not been found yet.

PRB Stick to facilitate stabilization of ultrasound probe and prevent work-related musculoskeletal disorder

The authors propose a stabilizing aid to support arm of anesthesiologist during ultrasound guided procedures in the operating room.

Moonwalk in Cardiac anesthesia platform in Nepal

This editorial presents a short picture of the development of cardiac anesthesia and its current status in Nepal.