American Society Of Anaesthesiologists Physical Status Research Articles

Patient mortality after total hip arthroplasty revision surgery

BackgroundComplications following revision total hip arthroplasty can cause significant morbidity and have a high mortality rate. Patient age and American Society of Anaesthesiologists (ASA) physical status classification system score are important determinants of mortality following revision hip arthroplasty. There is a paucity of high-quality evidence assessing the risk of mortality following revision hip arthroplasty stratified by indications of surgery. The aim of this study is to compare survival of patients undergoing revision THA for different indications. MethodsThis retrospective case series reviewed the mortality rate following revision hip surgery performed by a single surgeon between 2009 and 2016 with a minimum 2 year follow up. Kaplan Meir analysis was performed using mortality as the end point. Log rank testing was used to determine if the indication for surgery conferred a difference in survival. ResultsOne hundred and ninety-eight consecutive cases were done using a tapered modular uncemented stem in 183 patients and were followed up for a mean period of 51.8 months (range, 24–121). Sixty patients died (67 % survivorship) during the follow up period with a 5-year survival rate of 78 %. Revision surgery performed for aseptic loosening had the best survival and hemiarthroplasty had the worst and differences in survival were statistically significant (P = 0.000002). ConclusionThe indication for revision surgery is an important criterion which must be given weightage along with age, functional status of patient and ASA physical status score while planning revision surgery and counselling patients.

Anaesthesia-related mortality within 24 h following 9,391,669 anaesthetics in 10 cities in Hubei Province, China: a serial cross-sectional study

The mortality risk related to anaesthesia in China remains poorly characterized. The objective of this study was to evaluate the anaesthesia-related mortality in terms of its incidence, changes, causes and preventability in Hubei, China, between 2017 and 2021 using a series of annual surveys. We prospectively collected information on patient, surgical, anaesthesia, and hospital characteristics for 9,391,669 anaesthesia procedures performed between 2017 and 2021 in 10 cities within Hubei Province, China. Anaesthesia-related death was defined as death that deemed to be entirely or partially attributable to anaesthesia, occurring within 24h following anaesthesia administration. All fatalities were scrutinized consecutively to determine their root causes and preventability. The incidence and patterns of anaesthesia-related deaths were analysed from 2017 to 2021. A mixed-effects model with a Poisson link function was fitted to evaluate the city-level annual changes in risk-adjusted incidence of anaesthesia-related deaths. 600 cases of anaesthetic deaths occurred from 2017 to 2021, yielding an incidence of 6.4 per 100,000 anaesthesia procedures [95% confidence interval (95% CI): 5.9, 6.9], and most were preventable (71.3%). There was a significant decrease from 2017 to 2021, in the incidences of anaesthesia-related death across all patients, those with American Society of Anaesthesiologists physical status (ASAPS) ≥III, and those who had general anaesthesia, with a percentage reduction of 57.6%, 59.1%, and 55.9%, respectively. The risk-adjusted annual changes indicated significant downward trends for the incidence of anaesthetic mortality from 2017 to 2018, 2019, 2020, and 2021. For instance, the risk-adjusted annual changes for the anaesthetic mortality incidence from 2017 to 2021 was-2.5 (95% CI:-1.4,-4.7). In this large, comprehensive database study conducted in Central China, the anaesthesia-related death incidence was 6.4 per 100,000. Notably, the incidence of anaesthesia-related deaths decreased between 2017 and 2021. However, further in-depth analysis is needed to understand the extent to which these trends represent a change in patient safety. Innovation and optimization of perioperative respiratory system management strategy (Hubei Technological Innovation Special Fund, 2019ACA167).

Comparison of Intra-Articular Injection and Femoral Nerve Block Using a Combination of Levobupivacaine with Clonidine for Postoperative Analgesia after Arthroscopic Anterior Cruciate Ligament ReconstructionA Randomised Double-Blind Clinical Trial

Introduction: Anterior Cruciate Ligament (ACL) is the most commonly injured ligament in the knee. Arthroscopic ACL reconstruction is the gold standard procedure for treating ACL tears. Good postoperative analgesia is the secret for immediate postoperative rehabilitation. Various techniques, such as Femoral Nerve Blocks (FNB), epidural blocks, adductor canal blocks, and Intra-Articular injections (IA), are used to manage postoperative pain. Aim: To compare the quality of postoperative analgesia using a combination of levobupivacaine with clonidine via IA and FNB in patients undergoing ACL reconstruction under spinal anaesthesia. Materials and Methods: This randomised, double-blinded trial was conducted at Pondicherry Institute of Medical Sciences, Puducherry, India, from August 2016 to May 2018. Forty patients with American Society of Anaesthesiologists (ASA) physical status I and II, aged between 18-60 years, undergoing arthroscopic ACL repair under spinal anaesthesia were randomly assigned to two groups, with 20 patients in each group. After the surgery, patients in group 1 received FNB with 15 mL of 0.25% levobupivacaine and 30 mcg clonidine, while patients in group 2 received IA with 15 mL of 0.25% levobupivacaine and 30 mcg clonidine. Parameters such as the total duration of sensory block, the need for rescue analgesia, and total analgesic consumption within 24 hours were recorded postoperatively. The data were analysed using Student’s unpaired t-test, Analysis of Variance (ANOVA), Chi-square test, and Fisher’s-exact test. Statistical analysis was performed using Statistical package for the Social Science (SPSS) software (version 20.0 and info version 3.5.1) for Windows, with a p-value <0.05 considered significant. Results: The quality of postoperative analgesia, including the total duration of block, the need for rescue analgesia, and total analgesic consumption within 24 hours, was similar in both groups. The total duration of block was 216±36.041 minutes for the FNB group and 224±47.395 minutes for the intra-articular group, with a p-value of 0.552. The time for rescue analgesia was 307±87.666 minutes for the FNB group and 305±82.00 minutes for the intra-articular group, with a p-value of 0.963. There were no significant differences between the groups in terms of sex, age, weight, or ASA physical status classification. Conclusion: The present study showed that the postoperative analgesia following arthroscopic ACL reconstruction was equally effective in both groups. Both combinations reduced postoperative pain, expedited the return of postoperative function, maintained vital parameters, and had no apparent side-effects. However, IA may be considered as the preferred option since it is easier to perform than a femoral block.

Incidence and Risk Factors of Surgical Site Infections after Elective Gastrointestinal Surgery: A Prospective Cohort Study

Introduction: Surgical Site Infection (SSI) is defined as an infection that occurs within an incisional wound within 30 days following the procedure. SSI continues to be a significant contributor to extended hospital stays and elevated morbidity, with significant mortality even with well-equipped operation theaters with modern sterilisation techniques, surgical equipment, proper antibiotic cover, and newer surgical methods. Proper identification of the risk factors and modification, if possible, is the only way to optimise surgical outcomes and reduce SSI. Aim: To assess the incidence of SSI and analyse the risk factors associated with SSI. Materials and Methods: A prospective cohort study was conducted from March 2020 to March 2022 at a rural medical college in the coastal area of Alappuzha district of Kerala, India. Patients over 18 years of age admitted for elective gastrointestinal (GI) surgery for various indications were included. Those presenting with pre-existing infections other than the indication for surgery and those undergoing laparoscopic surgeries were excluded. Operations were performed on the third day after admission for all patients. The incidence of SSI and its relation with age, gender, smoking, diabetes, preoperative serum albumin, White Blood Cell (WBC) count, type and duration of surgery, American Society of Anaesthesiologists (ASA) physical status, and surgical wound were analysed using the Chi-square test and Fisher’s exact test. Results: On analysis of 216 patients, variables such as smoking, diabetes, preoperative low serum albumin, higher ASA physical status, contaminated and dirty wound, and prolonged duration of surgery were strongly associated with the development of SSI. Conclusion: Patients with risk factors such as smoking, diabetes, preoperative low serum albumin, higher ASA physical status, contaminated and dirty wound, and prolonged duration of surgery should receive special attention to optimise surgical outcomes and mitigate the risk of infection.

Negative Pressure Pulmonary Oedema – Lessons learnt

A 56 year old female patient belonging to American Society of Anaesthesiologists Physical Status (ASA-PS) 1 underwent emergency laparoscopic appendectomy. Surgery was uneventful. After reversal of the neuromuscular blockade and extubation, patient sustained acute upper airway obstruction due to laryngospasm and developed negative pressure pulmonary oedema, which resolved after a period of about 15 hours of mechanical ventilation.

Preoperative Risk Factors and Prognostic Impact of Postoperative Complications Associated with Total Gastrectomy

Introduction: We evaluated the risk factors for patients with gastric cancer (GC) undergoing total gastrectomy (TG) that predict postoperative complications, including anastomotic leakage, postoperative pneumonia, and heart disease. Methods: We collected 106 patients who received TG for GC between May 2009 and May 2017 at Gunma University Graduate School of Medicine, including clinicopathologic, surgical, postoperative complication, laboratory test, and physiologic test data. Results: Of 106 patients, 92 (86.8%) had no complications, and 14 (13.2%) had complications. Univariate analyses revealed that a high American Society of Anaesthesiologists physical status (ASA-PS) and neutrophil-lymphocyte ratio (NLR) of ≥3.5 significantly correlated with postoperative complications. Multivariate analyses showed that high ASA-PS was an independent prognostic factor of postoperative complications. The cancer recurrence rate was 34.8% in the noncomplication group and 71.4% in the complication group. Conclusion: Patients with postoperative complications are prone to recurrence and poor prognosis. For patients with high-risk GC with poor ASA-PS and high NLR, more thorough perioperative management is essential.

Incidence of Intraoperative Hypotension and Bradycardia in Spinal Anaesthesia with 0.5% Bupivacaine alone and 0.5% Bupivacaine with Fentanyl for Abdominal Hysterectomy: A Cross-sectional Study

Introduction: Bupivacaine hydrochloride, when used for spinal anaesthesia, is associated with varying degree of hypotension and bradycardia. Intrathecal opioids provides haemodynamic stability and improves quality of perioperative analgesia. Aim: To compare the incidence of intraoperative hypotension, bradycardia and its side-effects when using 0.5% hyperbaric bupivacaine alone and with 25 µg fentanyl added to it for subarachnoid block for abdominal hysterectomy. Materials and Methods: This cross-sectional study was conducted at Government Medical College, Thrissur, Kerala, India from June 2019 to May 2020 on 96 American Society of Anaesthesiologists Physical Status (ASA-PS) I and II patients posted for total abdominal hysterectomy under lumbar subarachnoid block. They were divided into Group A and B, carrying 48 patients in each group. Group A received 3.3 mL of 0.5% hyperbaric bupivacaine alone. Group B received 3.3 mL of 0.5% hyperbaric bupivacaine and 25 µg fentanyl. Haemodynamic characteristics, analgesic properties and side-effects were compared between Group A and Group B. Data were entered in Microsoft Excel Software, and analysed using Statistical Package for the Social Sciences (SPSS) software version 16.0 and p-value <0.05 was considered as statistically significant. Results: The incidence of hypotension in group A was 41.7% and in group B was 39.6%. Incidence of analgesia was significantly higher in group B (group A - 181.2±4.9, group B - 220.9±13.9). In group A, no one had nausea and vomiting. In group B, 8.3% experienced nausea and vomiting and none in both groups experienced pruritus. Conclusion: There was no difference in the development of hypotension and bradycardia when fentanyl was added to bupivacaine for spinal anaesthesia and had the advantage of increased duration of postoperative analgesia.

The ASA score predicts infections, cardiovascular complications, and hospital readmissions after hip fracture - A nationwide cohort study

SummaryThis study examines the association between the ASA physical status classification score at hip fracture surgery and severe postoperative complications in patients aged 60 and older. Among both men and women, ASA scores consistently predict a wide range of complications including infections, cardiovascular complications, hospital readmissions, and death.IntroductionHip fractures are common in aging populations and associated with poor prognosis. This study examines how the American Society of Anaesthesiologists (ASA) physical status classification is related to severe complications among hip fracture patients including infections, cardiovascular diseases, hospital readmissions, and death.MethodsBased on a linkage of the Swedish National Inpatient Register with the Swedish National Registry for Hip Fractures (RIKSHÖFT), this study includes patients aged 60+ with first hip fracture between 1998 and 2017. We estimated associations between ASA score and complications during the hospital stay and during 1 year after hip fracture using multivariable-adjusted logistic regression and Cox proportional hazard regression.ResultsThe study population included 170,193 hip fracture patients of which 24% died and 39% were readmitted to hospital within 1 year. The most common complications were urinary tract infections, pneumonia, second hip fractures, and heart failure. Among both men and women, higher ASA scores were consistently associated with higher risks for all complications included in this study. The strongest associations were observed for heart failure, myocardial infarction, pneumonia, and death.ConclusionASA scores are routinely assessed in clinical practice and predict a wide range of postoperative complications among hip fracture patients. Since many complications may be preventable through adequate drug treatment, rehabilitation, and risk awareness, future studies should examine the mechanisms linking ASA scores to complication risk in order to improve preventive strategies. Particularly, the high risk of cardiovascular complications among patients with high ASA scores deserves clinical and scientific attention.

Intravenous Clonidine versus Intraperitoneal Clonidine for Postoperative Analgesia After Total Abdominal Hysterectomy: A Randomised Controlled Trial.

ObjectiveThis prospective randomised double-blind study was conducted to compare the effect of intravenous (IV) with intraperitoneal (IP) administration of clonidine with respect to analgesic efficacy and side effects.MethodsA total of 60 American Society of Anaesthesiologists (ASA) physical status class I and II patients, aged 35–60 years, undergoing total abdominal hysterectomy, were randomly divided into 2 groups. Standard general anaesthesia technique was used. All the patients in group IV received 3 μg kg−1 of IV clonidine after resection of the uterus along with 0.25% bupivacaine (20 mL intraperitoneally and 10 mL as wound infiltration), whereas patients in group IP received 10 mL of normal saline intravenously and 3 μg kg−1 of clonidine mixed with 0.25% bupivacaine (20 mL intraperitoneally and 10 mL as wound infiltration). Postoperative analgesia was provided with IV diclofenac every 8 hours and IV fentanyl (1 μg kg−1) on demand. Pain at rest, opioid consumption, level of sedation and severity of nausea were recorded for 24 hours. The heart rate (HR) and blood pressure (BP) were recorded at an interval of 15 minutes for 2 hours followed by routine hourly monitoring.ResultsBoth the groups were found to be similar with respect to demography and ASA physical status. The maximum pain was felt at 6 hours in both the groups. The mean visual analogue scale score at 6 hours (p=0.47) was comparable. However, patients in group IV had significantly higher sedation (p<0.001) and nausea (p=0.013) scores on arrival at post-anaesthesia care unit along with a significant reduction in HR (p=0.001) and BP (p=0001) for the first 2 hours postoperatively.ConclusionAlthough IP clonidine is comparable with IV clonidine with respect to postoperative pain scores and supplementary opioid requirement, the side effects are significantly less with IP clonidine.

Intraoperative Temperature Monitoring with Zero Heat Flux Technology (3M SpotOn Sensor) in Comparison with Tympanic and Oesophageal Temperature and Hypotermia Risk Factors: An Observational Study.

ObjectiveInadvertent hypothermia (body temperature below 35°C) is a common and avoidable challenge during surgery under anaesthesia. It is related to coagulation (clotting) disorders, an increase in blood loss, and a higher rate of wound infection. One of the methods for non-invasive monitoring of the core body temperature is the 3M SpotOn zero heat flux method. In this approach, sensors placed at the frontal region of the patient measure the skin temperature by creating an isothermic channel. The study aimed to determine the risk factors for hypothermia and compare the 3M SpotOn zero heat flux method with the tympanic membrane (eardrum) and oesophageal (food pipe) temperature measurement methods.DesignObservational.Data sourcesThe patients’ data were collected, including age, gender, weight, BMI, other illnesses, smoking history, type of anaesthesia, duration of surgery, operating room temperature, pulse rate, blood pressure, blood loss, and transfusions. Body temperature was measured by the tympanic membrane method before and after surgery, oesophageal method during surgery, and SpotOn measurements throughout all three periods were recorded.Eligibility criteriaInclusion criteria was: adult patients, both genders, who had undergone major abdominal cancer surgery at the trialists’ institution, in whom the SpotOn zero heat flux, tympanic membrane, and oesophageal temperature measurement methods had all been used. Participant exclusion criteria was the absence of recorded data.ResultsIn this study, inadvertent intraoperative hypothermia incidence was 38.1% in the recovery room. Although gender, presence of comorbidities, history of smoking, administration of epidural anaesthesia, and requirement of blood transfusion [red blood cells (RBCs) and fresh frozen plasma (FFP)] did not affect hypothermia significantly during admission to the recovery room, prewarming the patient throughout the operation prevented the occurrence of hypothermia significantly (p=0.004). Additionally, as the American Society of Anaesthesiologists (ASA) physical status score worsened, the rate of hypothermia increased significantly (Frequency: 1st degree, 29.4%; 2nd degree, 47.5%; 3rd degree, 66.7%; X2Slope- p=0.047).ConclusionThe most significant risk factor was found to be not prewarming the patient as a strict procedure, and as the ASA physical status score worsened, the rate of hypothermia increased significantly. Besides, the SpotOn method provided temperature measurements as good as the oesophageal temperature measurements. Clinical Trial registration: ISRCTN 14027708.

Perioperative risk factors for recovery room delirium after elective non-cardiovascular surgery under general anaesthesia

BackgroundAlthough postoperative delirium is a frequent complication of surgery, little is known about risk factors for delirium occurring in the post-anaesthesia care unit (PACU). The aim of this study was to determine pre- and intraoperative risk factors for the development of recovery room delirium (RRD) in patients undergoing elective non-cardiovascular surgery.MethodsRRD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected perioperative data in 228 patients undergoing elective non-cardiovascular surgery under general anaesthesia and performed univariate and multivariate logistic regression to identify risk factors related to RRD. PACU and postoperative events were recorded to assess the outcome of RRD.ResultsFifty-seven patients (25%) developed RRD. On multivariate analysis, maintenance of anaesthesia with inhalation anaesthetic agents (OR = 6.294, 95% CI 1.4–28.8, corrected p = 0.03), malignant primary disease (OR = 3.464, 95% CI = 1.396–8.592, corrected p = 0.018), American Society of Anaesthesiologists Physical Status (ASA-PS) III–V (OR = 3.389, 95% CI = 1.401–8.201, corrected p = 0.018), elevated serum total or direct bilirubin (OR = 2.535, 95% CI = 1.006–6.388, corrected p = 0.049), and invasive surgery (OR = 2.431, 95% CI = 1.103–5.357, corrected p = 0.035) were identified as independent risk factors for RRD. RRD was associated with higher healthcare costs (31,428 yuan [17,872–43,674] versus 16,555 yuan [12,618–27,788], corrected p = 0.002), a longer median hospital stay (17 days [12–23.5] versus 11 days [9–17], corrected p = 0.002), and a longer postoperative stay (11 days [7–15] versus 7 days [5–10], corrected p = 0.002]).ConclusionsIdentifying patients at high odds for RRD preoperatively would enable the formation of more timely postoperative delirium management programmes.

Inferior Venacaval Ultrasonography to Detect Pre-Operative Hypovolemia as a Predictor of Postinduction Hypotension

Background: Hypotension is a common side effect of general anaesthesia, and when severe, it may lead to adverse outcomes. Ultrasonography of Inferior Vena Cava (IVC) is an effective, non-invasive method of assessment of intravascular volume status and hence the risk of hypotension at induction of anaesthesia. This study investigated whether preoperative ultrasound guided IVC measurements could predict hypotension after induction of anaesthesia. Methods: After ethical committee approval, this study was conducted at Sri Ramakrishna Hospital, Coimbatore. Written and informed consent was obtained. Forty six (46) adult patients, conforming to American Society of Anaesthesiologists physical status I to II, scheduled for elective surgery under general anaesthesia were recruited. Maximum IVC Diameter (dIVCmax) and Collapsibility Index (CI) were measured preoperatively. Before induction, Mean Blood Pressure (MBP) was recorded. After induction, MBP was recorded for 10 consecutive minutes. Hypotension was defined as greater than 30% decrease in MBP from baseline or MBP less than 60 mmHg. Results: IVC could not be visualized in 6 patients. Data from remaining 40 patients were analysed, of whom 26 patients (65%) developed hypotension. The incidence of hypotension in patients with CI>40% was 100% and when CI<40% it was 4%. The mean value of IVC maximum diameter was 1.60 cm and the mean value of IVC minimum diameter was 1.02 cm. The optimal cut-off value was 40% for CI among the patients who developed hypotension. CI was positively associated with a percentage decrease in MBP. Conclusion: Preoperative ultrasound IVC-CI measurement is a reliable predictor of hypotension after induction of general anaesthesia, and CI greater than 40% was highly significant in causing post induction hypotension.

Development and Validation of a Multivariable Prediction Model of Perioperative Mortality in Vascular Surgery: The New Zealand Vascular Surgical Risk Tool (Nzrisk-Vasc)

Introduction: Risk calculators and prediction models are available to assist clinicians and patients in their peri-operative decision-making to optimise the outcome [1]. In a vascular surgical setting, the majority of these instruments are based on abdominal aortic aneurysm repair outcomes, and in general their clinical use is limited due to variability in their predictive ability at procedural and institutional levels [2]. The objective of this study was to develop and validate a simple and accurate vascular surgical risk-prediction model. Methods: Ethical approval was obtained for the study. National administrative database was accessed to collect information on all adult patients undergoing vascular surgery between 1st of July 2011 and 30th of June 2016 in New Zealand. The database was split randomly into a derivation (75%) and a validation (25%) dataset. The primary outcomes were mortality at 30-days, 1-year and 2-years. Previously established covariates including American Society of Anaesthesiologists physical status (ASA-PS), sex, surgical urgency, history of cancer and ethnicity were tested and other covariates such as smoking status, presence of renal failure, diabetes, anatomical site of operation and structure operated on (artery, vein, arterio-venous, amputations) and type of procedures (open and endovascular) were explored. LASSO regression was used to select variables for inclusion in the model. Results: A total of 21,597 cases formed our final risk-prediction model with co-variates including ASA-PS, gender, surgical urgency, cancer status, presence of renal failure, diabetes, anatomical site, structure and endovascular procedure. The area under the receiver operating curve (AUC) for the 30-day, 1-year and 2-year mortality using LASSO regression was 0.87, 0.82 and 0.80 respectively, demonstrating very good discrimination. Calibration was also sufficient with calibration plot slopes of 0.90, 0.95 and 1.02 respectively. The strongest predictors of mortality included higher ASA-PS, diabetes, anatomical site of operation and structure. Conclusion: We have developed and validated a simple and accurate multivariate risk calculator for vascular surgical patients in New Zealand with excellent discrimination and calibration for 30-day, 1-year and 2-year morality. This tool may assist with risk estimation and aid peri-operative decision-making for both clinicians and patients in a vascular surgical setting. Disclosure: Nothing to disclose

A study of anaesthesia-related cardiac arrest from a Chinese tertiary hospital

BackgroundThe present survey evaluated the incidence of perioperative cardiac arrests in a Chinese tertiary general teaching hospital over ten years.MethodsThe incidence of cardiac arrest that occurred within 24 h of anaesthesia administration was retrospectively identified in the Third Affiliated Hospital of Sun Yat-Sen University between August 2007 and October 2017. Overall, 152,513 anaesthetics were included in the study period. Data collected included patient characteristics, American Society of Anaesthesiologists (ASA) physical status score, surgical specialty and anaesthesia technique. Cardiac arrests were assigned to one of three groups: “anaesthesia-related”, “anaesthesia-contributing” or “anaesthesia-unrelated”.ResultsIn total, 104 cardiac arrests (6.8:10,000) and 34 deaths (2.2:10,000) were obtained. Among them, eleven cardiac arrests events were anaesthesia-related, resulting in an incidence of 0.7 per 10,000 anaesthetics. Sixteen cardiac arrests events were found to be anaesthesia-contributing, resulting in an incidence of 1.0 per 10,000 anaesthetics. Cardiovascular adverse events were the major events that contributed to anaesthesia-related cardiac arrest. Differences were found between events related and unrelated to anaesthesia with regard to ASA physical status and anaesthesia technique (P < 0.05).ConclusionsAnaesthesia-related cardiac arrest occurred in 11 of 104 cardiac arrests within 24 h of anaesthesia administration. Most cardiac arrests related to anaesthesia were due to cardiovascular events, including arrhythmia and hypotension after intravenous narcotic, as well as haemorrhage. ASA physical status of at least 3 and subarachnoid block appeared to be relevant risk factors for anaesthesia-related cardiac arrest.

Paediatric procedural sedation at a tertiary care university teaching hospital in India

Introduction: Although paediatric procedural sedation (PPS) using propofol is routine in the United States, its use is restricted to anaesthesiologists in many other countries like India. As a result the paediatric providers have to use other drugs for PPS. Objective: To report a single centre experience of children receiving PPS at a tertiary care university teaching hospital. Method: A retrospective chart review of PPS at Goa Medical College, Goa, India was provided by the paediatric senior resident, supervised by a paediatric consultant, both certified in Paediatric Advanced Life Support (PALS) and with experience in non-propofol PPS. We collected demographics, drug and dosing information, indication for PPS, procedure success rates and adverse events. Sedation related minor adverse events are complications during PPS, which are easily handled, and not expected to be associated with any sequelae. Serious adverse events include aspiration, airway obstruction, laryngospasm, emergent anaesthesia consult, cardiac arrest and death. Results: Procedural sedation from 249 children from April-September 2015 were included in this study. Magnetic resonance imaging (MRI) 138/249 (55.4%), computed tomography (CT) scan 61 (24.5%), electroencephalogram (EEG) 26 (10.4%) and other procedures 24 (9.6%). Median age was 22 months (25th – 75th: 12-36), 140 (56.2%) were female, and 227 (91.5%) were American Society of Anaesthesiologists Physical Status (ASA-PS) ≤III. Overall success was 213 (85.5%). Commonly used agents included intravenous (IV) midazolam 188 (75.5%), IV dexmedetomidine 37 (14.9%), and oral chloral hydrate 24 (9.6%). Ramsey sedation score of 3 or greater was achieved in 220 (88.4 %) sedation after adding a second drug. Serious adverse events were seen in 3 (1.2%) patients. Sedation related minor adverse effects included: change in heart rate (>25% from baseline) 47 (18.9%), oxygen desaturation ( Conclusion: Intravenous midazolam was the commonest agent used for procedural sedation at Goa Medical College, India. Sri Lanka Journal of Child Health, 2018; 47 (1): 8-15

Thyroidectomy under local anaesthesia at a medical mission in a poor rural community: A safe alternative in selected patients

Background: Surgical missions have become regular in rural sub Saharan Africa, and these have helped to cater for surgical needs in these areas. Major surgeries are often performed in these areas amidst poor facilities for evaluation and treatment. Careful patient selection for thyroidectomy under local anaesthesia results in good surgical outcomes, and these can be replicated successfully with great care in these rural settings.Methodology: A descriptive study of thyroidectomies done under local anaesthesia in select patients during a 2-week medical mission by Pro-Health International in Weala, Liberia. Twelve patients presented with goitres, with ages ranging from 28 to 80 yrs. Inclusion criteria for selecting patients for surgery were those undergoing first time neck surgery, small or moderate sized goiters without toxic or malignant features, sleeping pulse of less than 80 and American Society of Anaesthesiologists Physical Status (ASA-PS) I and II.Results: Only 3 patients out of the 12 patients met the criteria. They all had subtotal thyroidectomy done successfully under local anaesthesia. One patient with moderate goitre received whole blood transfusion for primary haemorrhage. The postoperative period was uneventful.Conclusion: With proper selection, thyroidectomy under local anaesthesia can be useful and effective in a poor healthcare facility.

Optimal site for ultrasound-guided venous catheterisation in paediatric patients: an observational study to investigate predictors for catheterisation success and a randomised controlled study to determine the most successful site.

IntroductionVenous catheterisation in paediatric patients can be technically challenging. We examined factors affecting catheterisation of invisible and impalpable peripheral veins in children and evaluated the best site for ultrasound-guided catheterisation.MethodsSystolic pressure, age, sex, and American Society of Anaesthesiologists (ASA) physical status were determined in 96 children weighing less than 20 kg. Vein diameter and subcutaneous depth were measured with ultrasound. Logistic regression was used to evaluate the contribution of these factors to cannulation success with (n = 65) or without (n = 31) ultrasound guidance. Thereafter, we randomly assigned 196 patients for venous catheter insertion in the dorsal veins of the hand, the cephalic vein in the forearm, or the great saphenous vein. Success rates and vein diameters were evaluated by using Dunn tests; insertion time was evaluated by using Kaplan-Meier cumulative incidence analysis.ResultsIndependent predictors of catheterisation were ultrasound guidance (odds ratio (OR) = 7.3, 95% confidence interval (CI) 2.0 to 26.0, P = 0.002), vein diameter (OR = 1.5 per 0.1 mm increase in diameter, 95% CI 1.1 to 2.0, P = 0.007), and ASA physical status (OR = 0.4 per status 1 increase, 95% CI 0.2 to 0.9, P = 0.03). Cephalic veins were significantly larger (cephalic diameter 1.8 mm, P = 0.001 versus saphenous 1.5 mm, P <0.001 versus dorsal 1.5 mm). Catheterisation success rates were significantly better at the cephalic vein than either the dorsal hand or saphenous vein (cephalic 95%, 95% CI 89% to 100%, P <0.001 versus dorsal 69%, 95% CI 56% to 82%, P = 0.03 versus saphenous 75%, 95% CI 64% to 86%).ConclusionsThe cephalic vein in the proximal forearm appears to be the most appropriate initial site for ultrasound-guided catheterisation in invisible and impalpable veins of paediatric patients.Trial registry numberUMIN Clinical Trials Registry as UMIN000010961. Registered on 14 June 2013.

Comparison of Bier's block with Lidocaine versus Lidocaine plus Verapamil

Background: General anaesthesia and regional anaesthesia both are used for upper extremity surgeries. Bier’s Blockusing local anaesthetic alone or in combination with other adjuvants provides effective analgesia intraoperatively as wellas postoperatively with fewer complications as compared to general anaesthesia.Objective: This study was designed to compare effectiveness, haemodynamic alterations and total duration of analgesiawith Lidocaine versus Lidocaine plus Verapamil in Bier’s Block.Methods: This is a prospective randomised double blind trial conducted in Kathmandu Medical College TeachingHospital from February 2012 to December 2012 after approval from the ethical committee and informed consent fromthe participants. Total 40 adult patients of age 20 to 50 years, weight 50 to 70 kg, of both gender, belonging to AmericanSociety of Anaesthesiologists Physical Status I and II undergoing elective distal upper extrimity surgery lasting at one toone and half hours with Bier’s Block were included in this study. They were randomly divided into two groups of twentyeach to receive either 40 ml of 0.5% Lidocaine alone (Group A) or 40 ml of 0.5% Lidocaine plus 2.5 mg Verapamil (GroupB). The two groups were compared in terms of onset and recovery from sensory and motor blockade, tourniquet paintolerance time, duration of analgesia, alteration of haemodynamics and major side effects. Data analysis was done byMicrosoft Offi ce Excel 2007 [Polystat, Microsoft Offi ce Excel worksheet.XLS] using student’s two tailed t test. Categoricalparamatres were tested by Fisher Exact test and p-value of &lt;0.05 was considered statistically signifi cant.Result: Onset of sensory blockade was faster in group B (Mean± SD: 3.07± 0.25 minutes) as compared to group A (Mean±SD: 5.59 ± 0.41 minutes). The onset of motor block in group B was 10.4 ± 0.77 minutes versus 13.17 ± 1.45 minutes ingroup A. Recovery of sensory block in group B occurred at 29.95 ± 6.96 minutes versus 11.45 ± 2.16 minutes in groupA. Similarly recovery of motor block in group B occurred in 13.6 ± 1.79 minutes versus 7.65 ± 1.04 minutes in group A.Tolerance of fi rst tourniquet pain in group B was long 41.15 ± 3.82 minutes versus 22.00 ± 2.9) minutes in group A. Secondtourniquet pain tolerance time was again longer (48.25 ± 3.96 minutes) in group B versus 28.05 ± 4.84 minutes in groupA. Total duration of analgesia was more in group B (207.25 ± 21.1 minutes) versus 32.2 ± 5.78 minutes in group A. Totalconsumption of analgesic (Tramadol) in 24 hours in group B was lesser than group A (47.5 ± 38.0 mg versus 112.5 ± 35.8mg). All these differences were signifi cant statistically (p value &lt;0.05). Both of the groups showed stable haemodynamicparameters intraoperatively as well as postoperatively without any signifi cant adverse effects.Conclusion: Addition of Verapamil to Lidocaine was more effective than Lidocaine alone in Bier’s block.DOI: http://dx.doi.org/10.3126/jkmc.v2i1.10513Journal of Kathmandu Medical College, Vol. 2, No. 1, Issue 3, Jan.-Mar., 2013, Page: 12-17

The effect of dexmedetomidine infusion on propofol requirement for maintenance of optimum depth of anaesthesia during elective spine surgery

Background:Maintenance of adequate depth of anaesthesia in spine surgery is vital to prevent awareness, to reduce stress response and possible autonomic instability frequently associated with spine surgery. Dexmedetomidine, a α2-adrenoceptor agonist with analgesic and sedative adjuvant property has been found to reduce dose requirement of multiple anaesthetic agents both for induction and during the maintenance of anaesthesia.Aim:The aim of this study is to observe the effect of dexmedetomidine, on the requirement of propofol for induction and maintenance of adequate depth of anaesthesia during spine surgery.Methods:It was a prospective, randomised, double-blinded, parallel group, placebo controlled and open-lebel study in tertiary care hospital. A total of 70 patients aged 20-60 years, American Society of Anaesthesiologists GradeI and II, scheduled for elective spine surgery were randomly allocated into two groups. Each patient of Group D (n=35) received an initial loading dose of dexmedetomidine at 1 μg/kg over 10 min, started 15 min before induction of anaesthesia followed by an infusion at a rate of 0.2 μg/kg/h. Patients of Group P (n=35) received the same volume of 0.9% normal saline solution as placebo. Requirement of propofol at induction and during maintenance was calculated maintaining bispectral index between 40 and 60. P<0.05 was considered to be statistically significant.Results:Mean requirement of propofol was found to be lessened by 48.08% and 61.87% for induction and maintenance of anaesthesia respectively while using dexmedetomidine.Conclusion:Administration of dexmedetomidine significantly reduces the requirement of propofol while maintaining desired depth of anaesthesia without any significant complication.

Dose sparing of induction dose of propofol by fentanyl and butorphanol: A comparison based on entropy analysis

Background:The induction dose of propofol is reduced with concomitant use of opioids as a result of a possible synergistic action.Aim and Objectives:The present study compared the effect of fentanyl and two doses of butorphanol pre-treatment on the induction dose of propofol, with specific emphasis on entropy.Methods:Three groups of 40 patients each, of the American Society of Anaesthesiologistsphysical status I and II, were randomized to receive fentanyl 2 μg/kg (Group F), butorphanol 20 μg/kg (Group B 20) or 40 μg/kg (Group B 40) as pre-treatment. Five minutes later, the degree of sedation was assessed by the observer's assessment of alertness scale (OAA/S). Induction of anesthesia was done with propofol (30 mg/10 s) till the loss of response to verbal commands. Thereafter, rocuronium 1 mg/kg was administered and endotracheal intubation was performed 2 min later. OAA/S, propofol induction dose, heart rate, blood pressure, oxygen saturation and entropy (response and state) were compared in the three groups.Statistical Analysis:Data was analyzed using ANOVA test with posthoc significance, Kruskal–Wallis test, Chi-square test and Fischer exact test. A P<0.05 was considered as significant.Results:The induction dose of propofol (mg/kg) was observed to be 1.1±0.50 in Group F, 1.05±0.35 in Group B 20 and 1.18±0.41 in Group B40. Induction with propofol occurred at higher entropy values on pre-treatment with both fentanyl as well as butorphanol. Hemodynamic variables were comparable in all the three groups.Conclusion:Butorphanol 20 μg/kg and 40 μg/kg reduce the induction requirement of propofol, comparable to that of fentanyl 2 μg/kg, and confer hemodynamic stability at induction and intubation.