Adequate Anesthesia Research Articles

Efficacy of Clavipectoral Fascia Plane Block as Analgesic Modality in Clavicle Fractures: Exploring New Horizons

Clavicle fractures are commonly encountered in orthopedic outpatient department but are often managed conservatively. Yet some clavicle fractures need surgical intervention which in turn demand adequate anaesthesia and analgesia. Due to complex sensory innervation there is no sole regional anaesthesia technique which could provide adequate analgesia for clavicle fractures. With the advent of ultra-sonography (USG) and the description of clavipectoral fascia plane block (CPB) by Dr. Valde a lot was simplified. Administration of CPB provides intra as well as postoperative analgesia, maintains hemodynamics, reduces opioid consumption and improvises postoperative recovery of the patients undergoing clavicle surgeries.

POSSIBILITIES OF USING THE PHASEGRAPHY METHOD AS A MARKER OF ISCHEMIC CHANGES IN THE MYOCARDIA IN CARDIAC SURGICAL PATIENTS WHO HAVE UNDERGONE ARTOCORONARY BYPASS WITH THE USE OF ARTIFICIAL CIRCULATION

Introduction. Heart rate variability is a non-invasive method used to assess the modulation of the autonomic nervous system in the sinus node of the heart, which reflects the variability of the durations of successive R-R intervals on electrocardiograms. Phasagraphy is an innovative method of cardiology that allows to estimate the indicator of βT - symmetry of the T wave, which reflects the period of early repolarization of the heart.
 The aim. To expand the diagnostic criteria for perioperative hemodynamic disorders in patients who underwent surgery - coronary artery bypass grafting with cardiopulmonary bypass.
 Materials and methods. 500 patients were operated on at the State Institution of Science «Research and Practical Center of Preventive and Clinical Medicine» State Administrative Department. All underwent coronary artery bypass graft surgery with cardiopulmonary bypass. 80 patients were selected and examined by Fazagraf®, βT and LF / HF were analyzed. The main group included 35 patients who developed hemodynamic disorders in the early postoperative period. Inotropic support with dobutamine and metabolic support with a combination of levocarnitine and arginine were used to stabilize hemodynamics. The control group included 45 patients who did not have hemodynamic disorders.
 Results. At the stages of this study, the stability of LF/HF values was recorded, which indicates the adequacy of perioperative anesthesia and analgesia. The LF/HF in the preoperative period of the main group differed from the control group. After stabilization of hemodynamics LF/HF reached reference values. In order to correct acute left ventricular failure with dobutamine and the combination of levocarnitine and arginine in the main group of patients, the βT index shifted to the zone corresponding to the "health" of the myocardium.
 Conclusions. The LF/HF value reliably reflects the ratio of sympathetic and parasympathetic parts of the autonomic nervous system. An increase in LF/HF before surgery indicates the risk of hemodynamic disorders after surgery, and its decrease in the postoperative period - to stabilize the patient's condition. βT is associated with clinical data on myocardial status and can be used to determine myocardial health in patients with coronary heart disease. The combination of levocarnitine and arginine has a pronounced metabolic effect on the myocardium, which underwent surgery with cardiopulmonary bypass.

Spectral edge frequency during general anaesthesia: A narrative literature review.

Previous studies have attempted to determine the depth of anaesthesia with different anaesthetic agents using electroencephalogram (EEG) measurements with variable success. Measuring depth of anaesthesia is confounded by the complexity of the EEG and the fact that different agents create different pattens. A narrative review was undertaken to examine the available research evidence on the effect and reliability of spectral edge frequency (SEF) for assessing the depth of anaesthesia in adult patients under general anaesthesia. A systematic search of the PubMed®, Scopus®, CINAHL and Cochrane databases identified six randomized controlled trials and five observational studies. The findings of these studies suggest that SEF varies according to the anaesthetic drugs used. Remifentanil and age are two factors that can affect SEF, while other opioids and benzodiazepine (administered separately) seem to have no effect. No patients experienced intraoperative awareness. However, this does not indicate that SEF can provide full protection against it and the number of articles in which intraoperative awareness was studied was too small to afford any certainty. None of the studies demonstrated a reliable SEF interval associated with adequate general anaesthesia. SEF must be adapted to the anaesthetic drug used, the patient’s age and state while under general anaesthesia.

Comparison of Deep Learning Algorithms in Predicting Expert Assessments of Pain Scores during Surgical Operations Using Analgesia Nociception Index.

There are many surgical operations performed daily in operation rooms worldwide. Adequate anesthesia is needed during an operation. Besides hypnosis, adequate analgesia is critical to prevent autonomic reactions. Clinical experience and vital signs are usually used to adjust the dosage of analgesics. Analgesia nociception index (ANI), which ranges from 0 to 100, is derived from heart rate variability (HRV) via electrocardiogram (ECG) signals, for pain evaluation in a non-invasive manner. It represents parasympathetic activity. In this study, we compared the performance of multilayer perceptron (MLP) and long short-term memory (LSTM) algorithms in predicting expert assessment of pain score (EAPS) based on patient′s HRV during surgery. The objective of this study was to analyze how deep learning models differed from the medical doctors′ predictions of EAPS. As the input and output features of the deep learning models, the opposites of ANI and EAPS were used. This study included 80 patients who underwent operations at National Taiwan University Hospital. Using MLP and LSTM, a holdout method was first applied to 60 training patients, 10 validation patients, and 10 testing patients. As compared to the LSTM model, which had a testing mean absolute error (MAE) of 2.633 ± 0.542, the MLP model had a testing MAE of 2.490 ± 0.522, with a more appropriate shape of its prediction curves. The model based on MLP was selected as the best. Using MLP, a seven-fold cross validation method was then applied. The first fold had the lowest testing MAE of 2.460 ± 0.634, while the overall MAE for the seven-fold cross validation method was 2.848 ± 0.308. In conclusion, HRV analysis using MLP algorithm had a good correlation with EAPS; therefore, it can play role as a continuous monitor to predict intraoperative pain levels, to assist physicians in adjusting analgesic agent dosage. Further studies may consider obtaining more input features, such as photoplethysmography (PPG) and other kinds of continuous variable, to improve the prediction performance.

Clinical Evaluation of the Efficacy of Fitostimoline Hydrogel used for the Autolytic Debridement of Venous Ulcers

Venous ulcers are the most common type of chronic ulcers, affecting frequently the lower limbs. Chronic venous ulcers significantly impact quality of life because of pain, risk of infections, need of medications and possibility of malignant transformation [1]. Accurate wound assessment is essential to guarantee appropriate goal setting.Debridement and bacterial load control are two initial steps of wound care [2]. There are many procedures for wounds cleaning and to reduce bacterial bioburden. It is important the appropriate treatment choice for any single case. Firstly, venous ulcers often present fibrin, one of the major factor that prevents healing process, and for this reason, a debridement of fibrinous tissue is necessary [3]. There are different type of debridement (enzymatic, autolytic, surgical etc.) and the common choice of not aggressive debridement depends on the impossibility to obtain an adequate anesthesia at home or in first level/private offices. Autolytic debridement is a selective and not aggressive method which causes removal of necrotic tissue due to the physiological moist wound environment, which exerts its own debriding capacity [4]. It is a painless and safe technique with effective action and with low costs because dressing are usually changed every two days.

Spinal anesthesia in infants undergoing urologic surgery duration greater than 60 minutes

Spinal anesthesia (SA) has been safely utilized in infants. There are limited data regarding the safety and efficacy of SA in pediatric urologic surgery lasting ≥60min. We outlined the perioperative course for infants undergoing single-injection 0.5% plain bupivacaine SA-only for urologic procedures lasting ≥60min. To characterize the safety and efficacy of SA for urologic surgery in infants lasting ≥60min. We reviewed our prospectively maintained database of infants undergoing SA for urologic procedures lasting ≥60min from May 2018 to March 2021. Patients received preoperative intranasal dexmedetomidine, some received intranasal fentanyl, and all patients received lidocaine cream applied preoperatively over the lumbar spine. Oral sucrose on a pacifier was provided as needed, and the patient's arms were swaddled for the procedure. Success was defined as no conversion to general anesthesia. Time points for start/end of spinal injection, procedure duration, wheels in/out of operating room (OR), and discharge were collected. Of 245 cases conducted with SA during the study period, 76 (31%) infants underwent surgery lasting ≥60min. Of these, 73 (96%) were successfully completed with SA alone. In the 3 cases converted to general anesthesia, 2 (67%) required mask anesthesia after 96 and 169min (for the last <10min of surgery), and one was converted to intubation before start of surgery. Median patient age was 6 (IQR 5-7) months, and median procedure length was 95 (IQR 75-120) minutes. Following initial preoperative intranasal dexmedetomidine±fentanyl, at least one additional dose of IV sedative was given in 27 (36%) cases at a median time of 90 (IQR 60-120) minutes into surgery. Following closure, patients exited the OR after a median 10 (IQR 8-12) minutes and subsequently discharged after spending a median of 73 (IQR 61-96) minutes in recovery. We describe pediatric urologic surgical cases lasting ≥60min that employed single-injection intrathecal bupivacaine alone without adjunct intrathecal agents. In this report, SA was safely utilized in infants undergoing urologic procedures lasting at least 60min, with about 40% of patients receiving additional IV dexmedetomidine and fentanyl. Non-medication measures (swaddling, oral sucrose) were important for maximizing patient comfort. Communication between surgeon and anesthesia as cases progress is key to maintaining adequate anesthesia. A single-injection bupivacaine-only spinal anesthesia approach for urologic surgery lasting over an hour and up to 3h is safe and effective in infants. Selecting appropriate candidates for SA should be a joint decision between the surgeon and the anesthesiologist.

Comparison of cardiorespiratory and anesthetic effects of ketamine-midazolam-xylazine-sufentanil and tiletamine-zolazepam-xylazine in miniature pigs.

Effective and adequate anesthesia is conducive to better restrain for pigs during surgical or diagnostic procedures This study aimed to evaluate cardiorespiratory and anesthetic effects of ketamine-midazolam-xylazine-sufentanil or tiletamine-zolazepam-xylazine as general anesthetics in miniature pigs. In phase 1, one of the combinations was administered intramuscularly to miniature pigs. The KMXS protocol combined 10 mg kg-1 ketamine, 0.5 mg kg-1 midazolam, and 2 mg kg-1 xylazine with 2 μg kg-1 sufentanil. The TZX protocol combined 2.2 mg kg-1 tiletamine, 2.2 mg kg-1 zolazepam, and 1.4 mg kg-1 xylazine. After treatment, the mean arterial pressure, systolic arterial pressure, diastolic arterial pressure, heart rate, respiratory rate, peripheral hemoglobin oxygen saturation, rectal temperature, and anesthesia quality were recorded. In phase 2, the feasibility of KMXS and TZX as general anesthetics were evaluated for pig castration. In phase 1, both drug combinations provided smooth induction with similar anesthetic effects. The KMXS protocol provided moderate anesthesia for 60–70 minutes in pigs, while the TZX protocol provided 30–45 minutes. In phase 2, castration was completed smoothly in all pigs with little fluctuation in physiological variables. The KMXS protocol is better for medium-term anesthesia, while the TZX protocol is preferable for short-term anesthesia in pigs.

Digital nerve blocks: A systematic review and meta-analysis.

Study objectiveDigital nerve blocks (DNBs) provide local anesthesia for minor procedures of the digits. Several DNB techniques have been described, but it is unclear which technique provides adequate anesthesia with the least pain. DNB techniques can be grouped into a dorsal approach, which requires 2 injections, versus 3 different types of volar approaches, which require a single injection. We performed a meta‐analysis to compare DNB techniques with respect to time to anesthesia (TTA), duration of anesthesia (DOA), and pain of injection. We also reviewed data on degree and distribution of anesthesia and discuss the techniques preferred by study participants and clinicians performing injections.Data SourcesWe searched MEDLINE, EMBASE, and CENTRAL databases with terms “digital block,” “digital nerve block,” “local anesthetic,” “local anesthesia,” “lidocaine,” and/or “bupivacaine.”Study SelectionRandomized controlled trials (RCTs) were prioritized, though high‐quality prospective cohort studies were also eligible. All included studies evaluated DNB techniques or anesthetics. There were 23 papers (21 RCTs, 2 prospective descriptive studies) included.Data ExtractionDNBs studied included dorsal ring block, traditional dorsal block, transthecal block, modified transthecal block, and volar subcutaneous digital blocks. Outcomes measured included TTA, DOA, pain of injection scores, and degree of anesthesia.ResultsOverall, mean TTA was 4.5 minutes (95% confidence interval [CI] 3.5, 5.6), mean DOA was 187 minutes (95% CI 104.3, 269.7), and mean pain score was 2.1 out of 10 (95% CI 1.3, 2.8) without significant differences between studies or techniques.ConclusionsThere were no significant differences in the outcomes of TTA, DOA, and pain of injection between different DNB techniques. Single‐injection volar approaches may be preferred by participants and clinicians over dorsal approaches that require 2 injections, particularly with respect to pain. However, 2‐injection dorsal approaches may have better coverage of the proximal dorsal surface based on degree and distribution of anesthesia.

Expression of tyrosinase gene in gingiva: A pilot study.

Melanin is the predominant pigment responsible for the color of skin, hair, iris of eyes, and oral mucosa. Tyrosinase (TYR) is the key enzyme involved in melanin synthesis. Studies in dermatology have shown a positive correlation between TYR enzyme levels and melanin pigmentation of the skin. However, no study has been conducted to assess TYR levels in the gingiva. Hence the present study was conducted to assess TYR levels in gingival melanin hyperpigmentation. To assess the TYR gene expression in gingiva in individuals with moderate to severe gingival melanin hyperpigmentation. Subjects with a chief complaint of blackish appearance of gums with an unesthetic smile were included in the study. Informed consent was obtained. Scaling and root planning were done and subjects were recalled after 2 weeks. The gingival depigmentation procedure was performed using the conventional scalpel technique under adequate local anesthesia. The selected sites underwent conventional gingival depigmentation technique using Bard-Parker handle no: 3 and blade no: 11. The excised layer of epithelium along with a thin layer of underlying connective was sent to the laboratory to assess the TYR gene expression by real-time polymerase chain reaction technique. The levels of the TYR enzyme activity in the gingival tissues from the selected sites were assessed. Table 1 and Graph 1 show the levels of TYR enzyme gene expression in the gingival tissue. TYR gene expression and the degree of gingival melanin hyperpigmentation are positively correlated. Hence the assessment of TYR enzyme activity in gingiva could be of great value in today's cosmetologically conscious individuals.

Comparison of pain and extent of anesthesia in digital blocks for isolated finger lacerations: A randomized controlled trial.

OBJECTIVES:Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block (SV) technique. Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions.METHODS:This is a single-center prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anesthesia along with the anesthesia onset time.RESULTS:A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5.00] vs. 3.00 [2.00, 4.00], respectively, P = 0.006). However, anesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anesthesia was more predictable in the dorsal block compared to the volar block.CONCLUSION:The single-injection volar subcutaneous blocks are less painful with a similar anesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anesthesia of the region.

Dexmedetomidine in the Program of Multimodal Low-opioid Anesthesia During Laparoscopic Surgery in Urology

Dexmedetomidine, a highly selective α2-adrenergic agonist, has become a valuable component of low-opioid multimodal anesthesia, providing sedative, anxiolytic and analgesic effects. The objective: to evaluate the effectiveness of using dexmedetomidine in a multimodal low opioid anesthesia program for laparoscopic renal surgery. Materials and methods. 55 patients who underwent laparoscopic renal surgery under two types of general anesthesia were included. All patients underwent surgery under general anesthesia with tracheal intubation. Induction: intravenous propofol 2 mg/kg, fentanyl 1.5–2 μg/kg, atracurium 0.6 mg/kg. Anesthesia maintenance: sevoflurane (MAC – 1.44±0.25 vol.%). In group 1 analgesia was provided with fentanyl 3.89±2.1 μg/kg/h. Multimodal low-opioid anesthesia with fentanyl 2.38±1.01 μg/kg/h combined with dexmedetomidine 0.7 μg/kg/h was used in group 2. The efficacy of antinociceptive protection was assessed by the dynamics of changes in the levels of stress hormones, hemodynamic parameters, and blood glucose concentrations. Results. The total average doses of fentanyl used during the entire period of anesthesia were: 369.23±16.42 μg in group 1, 272.41±10,98 μg in group 2 (p&lt;0.001). In patients of the control group 1, an increase in the plasma concentration of adrenocorticotropic hormone by 111.86% (p&lt;0.01) from 25.7±2.1 pg/ml to 54.45±5.43 pg/ml was recorded (the study was conducted before the start of surgery and after the end of the operation), which was accompanied by a statistically significant increase cortisol concentration from 371.0±32.32 nmol/l to 562.72±45.37 nmol/l (by 51.67%) (p&lt;0.01). In patients of the second group (dexmedetomidine group), an intraoperative increase in the plasma concentration of adrenocorticotropic hormone was recorded from 26.25±2.3 pg/l to 46.88±2.36 pg/l (by 78.59%) (p&lt;0.01), which was accompanied by a statistically insignificant intraoperative increase in cortisol concentration from 393.51±25.0 nmol/l to 436.37±34.92 nmol/l – only by 10.89% (p&gt;0.05). Blood glucose concentrations in the early postoperative period in the both groups were 6.79±0.31 mmol/l and 6.29±0.24 mmol/l, respectively (p&gt;0.05). Hemodynamic parameters and BIS, which was maintained within 44±6.4%, indicated the adequacy of anesthesia and analgesia in both groups. Conclusions. The use of dexmedetomidine in multimodal low-opioid anesthesia for laparoscopic renal surgery provides the greatest antinociceptive protection and reduces the stress response to surgery.

Случай осложненного течения перелома дистального метаэпифиза лучевой кости

INTRODUCTION: Zudek syndrome (neuroreflex algodystrophy, accompanied by osteoporosis, limited range of motion in the wrist and interphalangeal joints, impaired blood flow and associated trophic alterations) accounts for up to 62% of complications of fracture of the distal metaepiphysis of the radius. It may be a consequence of primary action of pathological factors (I type), or may result from compression of peripheral nerves (II type). The article describes a clinical case illustrating occurrence of almost all critical errors in the treatment process (non-performance of local anesthesia of the fracture and of reposition of fragments; fixation of the hand in a vicious (for this type of fracture) flexion position for up to 3 weeks; lack of local physiotherapy, anti-inflammatory and kinesitherapeutic treatment; use of “aggressive” mechanotherapy in passive restoration of the volume of movements and of “hard” massage against the background pain syndrome) that contributed to the development of the given II type complication. As a result, a surgical correction was required — corrective osteotomy of the radius to eliminate the cause of compression of the ulnar and median nerves and restore the interrelations between the articular surfaces in the wrist joint. CONCLUSION: Non-observance of the principles of treatment of a fracture of the radius in a “typical place” (emergency care; adequate anesthesia; immediate sparing reposition; subsequent clinical and radiological control, functional management; sufficient period of immobilization; early physiotherapy and kinesitherapy; etc.) may provoke such a threatening complication as Zudek syndrome characterized by a prolonged disability and inflicting physical and moral suffering. Besides, it is associated with a high cost of treatment and restoration of the function of the damaged limb, significantly exceeding the economic standard.

Effect of Constant Rate Infusion of Different Anaesthetic Adjuvants Undergoing Thiopentone Sodium Total Intravenous Anaesthesia in Horses

Background: Co-administration of anesthetic adjuvants as continuous rate infusion (CRI) can be controlled and hence is considered safer, as it can reduce the cardiopulmonary alterations in horses and is also adaptable in field conditions. Hence this study was planned to evaluate the effect of CRI of dexmedetomidine, ketamine, butorphanol and midazolam during thiopentone TIVA in horses. Methods: Thirty horses were randomly divided into five groups S, D, K, B and M having six animals in each. Premedication was done with Xylazine (1 mg/kg) and butorphanol (0.05 mg/kg) intravenously. Ketamine (2 mg/kg) and midazolam (0.2 mg/kg) were used IV for induction. CRI of normal saline alone, dexmedetomidine @ 2 µg/kg/hr., butorphanol @ 0.2 mg/kg/hr., midazolam @ 0.2 mg/kg/hr. and ketamine @ 2 mg/kg/hr. were administered in groups S, D, B, M and K, respectively. Thiopentone sodium (5%) was given as a fast intravenous bolus whenever required to provide adequate anesthesia. Depth of anesthesia was evaluated on the based on clinical, haemato-biochemical, hemodynamic and endocrine variables. Result: First head lift, sternal recumbency time, standing time and quality of recovery showed no significant difference between the groups. Heart rate, RR, RT, SBP, DBP, CVP and MAP, BUN, creatinine, ALT, AST, cortisol, ACTH and ghrelin did not show significant variation among groups. Hb, PCV, TLC, TEC and neutrophil found significantly decreased and blood glucose remained significantly higher than the baseline value in all groups post induction. CRI of ketamine produced a better quality of recovery and thiopentone sparing effect and was found suitable for moderating stress response to anesthesia, inflammation and metabolic changes in horses administered with TIVA.

A Height-Based Dosing Algorithm of Bupivacaine in Spinal Anesthesia for Decreasing Maternal Hypotension in Cesarean Section Without Prophylactic Fluid Preloading and Vasopressors: A Randomized-Controlled Non-Inferiority Trial.

BackgroundThere is a high incidence of maternal hypotension in spinal anesthesia for cesarean section. The aim of the study is to investigate whether there is a height-based dosing algorithm of bupivacaine that provides adequate anesthesia with less maternal hypotension.MethodsThere were 2 groups of 280 parturients who did not receive prophylactic fluid preloading: Test and Conventional group. In Test group, a height based dosing algorithm was used to confirm the dose of bupivacaine in parturients without prophylactic vasopressors. In the Conventional group, a constant dose of bupivacaine was used. The complications and quality of anesthesia were evaluated.ResultsIn the Conventional group, the shorter participants had higher incidence of hypotension, faster sensory block time, and more participants with complete motor block (p = 0.030, 2.957 × 10−14, and 0.012). In the Test group, the incidence of hypotension, sensory block time, and number of participants with complete motor block did not change with height (p = 0.199, 0.617, and 0.209). The height-based dosing algorithm of bupivacaine decreased the incidence of hypotension (p = 0.004), induced lower sensory block level and less degree of motor block (p = 3.513 × 10−7 and 5.711 × 10−11). The quality of analgesia, quality of muscle relaxation, and degree of intraoperative comfort were similar in both groups (p = 0.065, 0.498, and 0.483).ConclusionsThe height influences the dose of bupivacaine in spinal anesthesia; without prophylactic fluid pre-loading and vasopressors, the height-based dosing algorithm of bupivacaine is suitable, and meets the cesarean section' requirement with less maternal hypotension.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier: NCT03497364.

Особенности анестезиологического обеспечения при проведении операций при повышенном внутриглазном давлении

Purpose. To develop an algorithm for selection of anesthetic drugs and their dosages for adequate and safe anesthesia during surgical interventions that are performed on patients to reduce elevated intraocular pressure and to minimize the complications that may arise during anesthesia. Methods. The study included 86 cases that underwent surgery to reduce elevated intraocular pressure; 34 surgeries were performed under sub-Tenon anesthesia (39.6 %), 2 under parabulbar (2.3 %) and 50 (58.1 %) under peribulbar regional anesthesia. All the patients underwent dynamic monitoring of homeostasis. Anesthesia support consisted of preoperative preparation, regional anesthesia and drugs administered as a bolus in the operating room. Results and discussion. A list of drugs used during operations performed with increased intraocular pressure has been compiled. The most rational and safe dosages of drugs have been determined. After the introduction of this algorithm, not a single complication was obtained as a result of anesthesia. Conclusions. Implementation of the algorithm for intraoperative anesthesia in patients with elevated intraocular pressure made it possible to achieve: 1) adequate nociceptive and psychoemotional protection; 2) comfort conditions both for patients and for medical personnel; 3) minimizing anesthetic risks and complications. Key words: anesthesiology; ophthalmology; glaucoma; increased intraocular pressure; regional anesthesia.

SECURITY AND FEASIBILITY STUDY OF AWAKE AIRWAY SURGICAL PROCEDURES

TYPE: Abstract TOPIC: Cardiothoracic Surgery PURPOSE: The objective is to show the secure and feasibility of local and regional management under awake anesthesia and spontaneous respiration in different airway pathologies to get a diagnosis and relieve in some cases of life-threatening disease. METHODS: Prospective clinical feasibility study for patients with upper tracheal pathology were managed with local anesthetics like spray lidocaine 10% and neural blockade by topicalization. Alternatively, we use 10 ml syringe with lidocaine 2% (n=3). All patients were taken to the operating room as an emergency procedure. The principal biochemical aspect for the emergency was CO2 retention. RESULTS: Thirty-three consecutive patients admitted to the emergency room with tracheal stenosis (n=18), laryngeal and tracheal tumors (n=7), fixed tracheostomy cannula with granuloma (n = 5), obstruction with foreign body (n=2) and tracheitis (n=1) were enrolled. There were 9 women (27.3%) and 24 men (72.7%), with mean age range from 33 to 67 years old. The time of the anesthetic procedure was average 5 minutes, with no complications and a safe management. Operations included pneumatic sequential dilatation, emergency tracheostomy, tracheoplasty and tracheal biopsy. CONCLUSIONS: Our work demonstrates the complete safety of the protocol with adequate local anesthesia that allows to perform procedures in different pathologies of the airway keeping the patient secure, awake and in most of the cases ensuring an ambulatory management. CLINICAL IMPLICATIONS: In high-risk patients where oral intubation can be difficult, impossible and is not an option because of the risk to collapse due to the airway pathology, an alternative is an awake and tubeless upper airway surgery. DISCLOSURE: Nothing to declare. KEYWORD: tracheal surgery

COMPARISION OF ONSET OF ACTION, DURATION AND INTUBATING CONDITIONS OF ROCURONIUM BROMIDE AND SUCCINYLCHOLINE IN ADULT PATIENTS.

Background: The major uses of muscle relaxation for surgery are: to facilitate endotracheal intubation and to provide surgical relaxation. Succinylcholine, with its rapid onset time, excellent intubating conditions, and short duration of action is a favourite of many anaesthesiologists for rapid endotracheal intubation. However, it falls short of the status of the ideal muscle relaxant - due to its life-threatening side effects such as hyperkalaemia, cardiac arrest and malignant hyperthermia. Rocuronium may serve as a useful alternative for many clinicians to facilitate endotracheal intubation, not only in elective cases under adequate anaesthesia, but also in emergency situations requiring rapid sequence intubation. The side effect prole of Rocuronium is way more limited, and way more acceptable to that of succinylcholine. While there have been many studies on the dosage of Rocuronium greater than /equal to 1mg/kg, which have demonstrated comparable onset and intubating conditions to succinylcholine, this study involves a lower dose(0.9mg/kg) elective surgery cases, where a minor difference in the time of onset is of no signicant concern. Objective: To compare onset of action, duration and intubating conditions of Rocuronium Bromide (0.9mg/kg) and Succinylcholine (1.5mg/kg) in adult ASA I and II patients posted for elective surgery. Method: this was a randomized, double-blind, prospective, clinical study conducted on 100 ASAI and II patients posted for elective surgery. Patients were divided into two groups using 'slips in the box technique': Group A– received Rocuronium bromide 0.9 mg/kg Group B – received Succinylcholine 1.5mg/kg Results: Ÿ The intubating conditions using Goldberg's score were acceptable in both groups= excellent or good conditions. Ÿ But the Succinylcholine group had more instances of excellent intubating conditions, and this difference was statistically signicant. p&lt;0.05 Ÿ The Mean arterial pressure increased after laryngoscopy in both groups, but its difference between the two groups was not statistically signicant at any time interval. p &gt;0.05 Ÿ In the Rocuronium group, 6 patients had signicant tachycardia. HR&gt;120, and 5 patients had hypotension (MAP&lt;60mm Hg) Ÿ In the Succinylcholine group, 7 patients had signicant tachycardia. HR&gt;120, and 6 patients had hypotension (MAP&lt;60mm Hg). Conclusion: this study reveals that Rocuronium, at a dose of 0.9mg/kg, is an effective substitute for Succinylcholine as the choice of muscle relaxant, and offers similar intubating conditions, at 1 minute. Considering the lower side effect prole, Rocuronium at the dose of 0.9 mg/kg can be the ideal choice for muscle relaxant during elective surgery

The effect of different anaesthesia techniques on postoperative pain and hospital discharge in varicose vein surgery.

Venous insufficiency caused by varicose veins, especially in the lower extremities, is widespread and can cause severe complications. Anaesthesia is essential for any surgical approaches in varicose vein surgery. This study evaluated the effect of single-dose epidural anaesthesia on postoperative pain scores and length of hospitalisation after varicose vein surgery, comparing it with general anaesthesia. The study was conducted on a total of 100 patients, aged 18 years and older, with the American Society of Anesthesiologists (ASA) physical status classification I-III, undergoing unilateral lower-extremity stripping due to varicose veins within a six-month period at the Prof Dr Cemil Taşçioğlu City Hospital Anesthesiology and Reanimation Service. Fifty patients with single-dose epidural anaesthesia were consecutively included in the EA group. For comparison, 50 patients who were operated on under general anesthesia were included in the GA group. The groups showed statistically significant differences between the 30th-minute and first-, second-, fourth- and sixth-hour visual analogue scale (VAS) scores (p = 0.001; p < 0.01). Patients with epidural anaesthesia had lower 30th-minute VAS scores compared to those administered general anaesthesia. There were statistically significant differences identified between the groups for the additional analgesia requirements of patients (p = 0.001; p < 0.01). Subjects with epidural anaesthesia had lower additional analgesic requirements than those administered general anaesthesia. Epidural anaesthesia provided adequate anaesthesia with more effective postoperative analgesia compared to patients operated on under general anaesthesia and receiving multimodal analgesia for postoperative analgesia.

Fulminant Orbital Myiasis - A Rare Case Report from Central India

A 42 year old male farmer presented to eye OPD with a history of painful, foul smelling discharging wound over the lower lid along the inferior orbital margin since two weeks and crawling sensation over the wound with diminution of vision right eye since three days. He gave history of trauma to right eye after falling on sharp edge of stone one month back when he was in a drunken state due to which he had a lacerated wound of about 5cm x 2 cm x 2cm along inferior orbital margin.&#x0D; The wound was cleaned and dressed only once at a local hospital, however, he neglected the wound and didn’t open the dressing for about next 15 days until he noticed a crawling sensation and maggots teeming from the wound. He denied a history of diabetes mellitus, hypertension or any other chronic systemic disease or any prolonged use of medications, progressive loss of weight or appetite. However, he was a chronic alcoholic. He belonged to low socioeconomic strata with poor personal hygiene and was residing in a rural area.&#x0D; On presentation, the patient was in agony due to pain. On examination of the right eye, the eyelids were severely oedematous and indurated with severe mechanical ptosis. The lower lid along the inferior orbital rim had a deep open, macerated wound of size about 5cm x 2cm x 2cm, filled with necrotic tissue (slough), discharge and around 5-6 maggots were seen teeming from the wound [Fig. 1]. The skin around the wound was red and friable. On separating the lids gently and mechanically, the conjunctiva was severely congested and chemosed. Unaided visual acuity was 3/60; best-corrected visual acuity could not be assessed as the patient was in agony due to pain. The cornea, anterior chamber and iris were normal. The pupil was normal-sized reacting to light. The eyeball had deviated inwards and ocular movements were painful and restricted in all directions. Lens had immature senile cataract. Intraocular pressure and nasolacrimal passage could not be assessed because of gross lid oedema. Fundus examination of the right eye was within normal limits. On examination of the left eye, unaided visual acuity was 6/18 and best-corrected visual acuity was 6/9. Anterior segment was within normal limits with pupil normally reacting to light and fundus examination was normal.&#x0D; Five to six superficially lying maggots were removed with the help of turpentine oil and forceps after adequate local anaesthesia. Many more deep-seated maggots were seen but were difficult to remove.

Combined femoral-obturator-sciatic nerve block has superior postoperative pain score and earlier ambulation as compared to spinal anaesthesia for arthroscopic anterior cruciate ligament reconstruction.

Peripheral nerve blocks can be a suitable alternative to central neuraxial blockage, as the sole anaesthetic agent for better early postoperative outcomes, decreased hospital stay and earlier mobilisation after anterior cruciate ligament reconstruction (ACLR) surgery. The purpose of this study was to compare consciousness during the procedure, pain during early postoperative period (< 7days), and perioperative outcomes following ACLR using combined sciatic, femoral, and obturator nerve blocks compared to the spinal anaesthesia. This was a prospective case-control study including patients between 18 and 55years of age, with anterior cruciate ligament (ACL) injury confirmed clinically and radiologically and undergoing ACLR. Patients were allocated in the two groups alternatively, group 1 included patients who received combined nerve blocks, and group 2 included patients who received spinal anaesthesia for the surgery. The sensory effect, motor effect, adequacy of anaesthesia, perioperative analgesic use, duration of stay, postoperative pain (visual analogue scale 0-10cm) and functional outcomes were noted. There were 60 patients in each group. A total of seven patients in group 1 (11%) and two patients in group 2 (3%) needed conversion to general anaesthesia (n.s.). In group 1, out of 53 patients who underwent surgery, 26 patients had no perception of surgery in the joint, 17 patients had perception of manipulation of the knee joint, 4 patients had sense of touch, and 6 patients had sensation of pain in the knee (VAS scale less than 3). In group 2, out of 58 patients, 42 patients had no perception of surgery, 12 had a perception of manipulation of the knee joint, 2 had sense of touch, and 2 had sensation of pain in the knee. Blockage of sensory effect was significantly better in group 2 (p = 0.0001). However, the motor effect was comparable between the two groups (n.s.). Group 1 had significantly better pain scores 6, 12, and 18h after the surgery. Moreover, patients in group 1 also had faster ambulation (mean difference of 5.5h, p = 0.0001) and reduced hospital stay (mean difference of 8.4h, p = 0.0001). Combined sciatic, femoral, and adductor canal block is an effective sole anaesthetic modality for ACLR. The sensory effect was inferior when compared to spinal anaesthesia but sufficient for the procedure without the need for supplementation with any other anaesthetic modality. Patients receiving this combined nerve block had lesser early postoperative pain scores, earlier ambulation, and shorter hospital stay as compared to the spinal anaesthesia. Level 3.