Hemodynamic Stability Of Patient Research Articles

Hemodynamic responses to insertion of the laryngeal mask airway versus Combitube

Introduction: One of the most common problems during laryngoscopy involves sympathetic system stimulation and the subsequent hemodynamic changes. It is a key measure to maintain the hemodynamic stability of patients with cardiovascular diseases during induction of anesthesia. This study attempted to compare the hemodynamic effects of laryngeal mask airway and combitube. Methods: This prospective clinical trial was conducted on a total of 142 candidate patients 18 to 60 years of age with ASA I and II undergoing elective surgery. Patients were randomly divided into three groups: (1) mask ventilation (control group) (2) laryngeal mask airway and (3) combitube. At the next stage, the systolic and diastolic blood pressures and heart rates were measured at the following points in time: baseline, after induction of anesthesia and before airway manipulation, 1, 3 and 5 minutes after ventilation. The findings were analyzed and P<0.05 was considered significant. Correspondence: Hashem Jarineshin, MD. Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Sciences. Bandar Abbas, Iran Tel:+98 9173613464 Email: hjarineshin@yahoo.com Results: Patients in all three groups were closely matched in terms of age, height, weight, sex and Mallampati score. The duration of combitube insertion was significantly longer than that of laryngeal mask airway (LMA) (P<0.05). The baseline and post-induction hemodynamic variables were similar in the three groups. The hemodynamic variations at the first minute were higher in the combitube group than the other two. At minute 3, the hemodynamic parameters in Groups 2 and 3 were significantly higher than those in Group 1. Moreover, diastolic blood pressure in Groups 2 and 3 was higher than that in Group 1 in the 5th minute. Conclusion: LMA insertion leads to lower hemodynamic responses in patients during airway management compared to combitube. This is can be an important issue in cardiovascular patients.

Effectiveness and Safety of Polygeline in Patients with Hypovolemia due to Trauma.

Background:This retrospective study examined the effectiveness and safety of polygeline in adult patients with hypovolemia due to traumatic injury.Materials and Methods:Polygeline was administered after evaluating the amount of blood loss and estimating hematological and biochemical parameters. Changes in vital signs, serum electrolytes, arterial pH, and serum lactate were evaluated. The safety was evaluated by recording the adverse events if any.Results:Sixty patients with the mean age 37.5 ± 11.26 years were included in the study. All patients had blood loss < 20%. The mean total polygeline administered was 1025.0 ± 464.18 ml. Blood transfusion was required in 3.33% of patients. Diastolic, systolic, and mean arterial blood pressure and pulse rate significantly increased after 1 h of polygeline administration (P < 0.0001). There was a trend toward increase in urine output (P = 0.0715) after 1 h. The improvement in vital parameters was consistent at 6, 14, and 18 h after administration of polygeline. Arterial pH significantly increased from 7.2 ± 0.12 to 7.3 ± 0.11 after 1 h of administration (P < 0.0001) and was consistent till 24 h (P = 0.035). Blood lactate decreased after 1 h (P < 0.0001). Changes in laboratory parameters were not clinically significant. After mean duration hospital stay of 10.5 ± 4.63 days all patients were discharged without any clinically significant abnormality or adverse event.Conclusion:Polygeline improved hemodynamic stability in patients with hypovolemia due to traumatic injury. The improvement was seen within 1 h (golden hour) of polygeline administration and maintained consistently. Polygeline can be safely administered to patients with traumatic injury to improve hemodynamic parameters and achieve stability.

A Comparison of Dexmedetomidine and Clonidine in Attenuating the Hemodynamic Responses at Various Surgical Stages in Patients Undergoing Elective Transnasal Transsphenoidal Resection of Pituitary Tumors.

Background:Transsphenoidal approach to pituitary tumors is a commonly performed procedure with the advantage of a rapid midline access to the sella with minimal complications. It may be associated with wide fluctuations in hemodynamic parameters due to intense noxious stimulus at various stages of the surgery. As duration of the surgery is short and the patients have nasal packs, it is prudent to use an anesthestic technique with an early predictable recovery.Materials and Methods:A total of 60 patients of either sex between 18 and 65 years of age, belonging to the American Society of Anesthesiologists I and II who were undergoing elective transnasal transsphenoidal pituitary surgery were chosen for this study. Patients were randomly allocated into two groups, Group C (clonidine) and Group D (dexmedetomidine), with each group consisting of 30 patients. Patients in Group C received 200 μg tablet of clonidine and those in Group D received a pantoprazole tablet as placebo at the same time. Patients in the Group D received an intravenous infusion of dexmedetomidine diluted in 50 ml saline (200 μg in 50 ml saline) 10 min before induction and patients in Group C received 0.9% normal saline (50 ml) as placebo. The hemodynamic variables (heart rate, mean arterial pressure) were noted at various stages of the surgery. Statistical analysis of the data was performed.Results:A total of 60 patients were recruited. The mean age, sex, weight and duration of surgery among the two groups were comparable (P > 0.05). Both dexmedetomidine and clonidine failed to blunt the increase in hemodynamic responses (heart rate and blood pressure) during intubation, nasal packing, speculum insertion and extubation. However when the hemodynamic response was compared between the patients receiving dexmedetomidine and clonidine it was seen that patients who received dexmedetomidine had a lesser increase in heart rate and blood pressure (P < 0.05) when compared to clonidine.Conclusions:A continuous intravenous infusion of dexmedetomidine as compared to oral clonidine improved hemodynamic stability in patients undergoing transnasal transsphenoidal resection of pituitary tumors.

Role of Methylene Blue in the Maintenance of Postinduction Hemodynamic Status in Patients with Perforation Peritonitis: A Pilot Study.

Context:Methylene blue is an inhibitor of guanylate cyclase and hence prevents vasoplegia mediated by nitric oxide in patients with sepsis.Aims:This study aimed to analyze the effect of methylene blue on blood pressure maintenance following induction of anesthesia in patients presenting with peritonitis.Subjects and Methods:Thirty patients diagnosed to have perforation peritonitis were randomized into two groups (Group MB, Group NS). Patients in Group MB were given injection methylene blue 2 mg/kg over 20 min and patients in Group NS were given 50 ml of normal saline over 20 min, before induction. Heart rate, mean arterial pressure (MAP), cardiac output, and systemic vascular resistance (SVR) were recorded every 5 min for 1 h after infusion.Statistical Analysis:Hemodynamic parameters were analyzed using repeated-measures analysis of variance with Bonferroni's test. Blood gas analysis was analyzed using independent Student's t-test, and P < 0.05 was considered statistically significant.Results:MAP was lower at all-time points in Group NS than Group MB; however, it was statistically significant immediately, and 5 min the following induction. MAP fell from 94.8 ± 11.8 mmHg to 89.2 ± 16.0 mmHg immediate postinduction in Group MB and from 92.1 ± 9.8 mmHg to 74.1 ± 12.6 mmHg in Group NS. MAP and SVR were significantly higher in Group MB, 5 min following induction. No adverse events attributable to methylene blue were noted.Conclusions:Methylene blue contributes to the maintenance of postinduction hemodynamic stability in patients with perforation peritonitis.

Comparative Study of the Effect of Dexmedetomidine Vs. Fentanyl on Haemodynamic Response in Patients Undergoing Elective Laparoscopic Surgery.

Dexmedetomidine and fentanyl, both have sedative and analgesic effects. They are often used as adjunct during anaesthesia to attenuate pressor response during tracheal intubation. Limited study has been done comparing the effect of both drugs on haemodynamic response in patients undergoing laparoscopic surgery. The study was designed to compare the effect of dexmedetomidine Vs fentanyl on haemodynamic response to tracheal intubation, following pneumoperitoneum and intraoperative period in patients undergoing laparoscopic surgery. Sixty patients of age group 18-60 years of either sex, classified as American Society of Anaesthesiologist (ASA) Grade I and II undergoing elective laparoscopy surgery were randomly allocated to one of the two groups (Group-D) and (Group F) of 30 each. Group D received dexmedetomidine and Group F received fentanyl. Patients received intravenous 0.5 μg/kg of the study drug as loading dose over 10 minutes prior to intubation followed by 0.2-0.7 μg/kg/hr as infusion till surgery was over. In operating room parameters like Heart Rate (HR), Respiratory Rate (RR), Systolic Blood Pressure (SBP), Mean Arterial Pressure (MAP), SpO2, EtCO2 were recorded 10 minutes after infusion of drug i.e., dexmedetomidine or fentanyl. The said parameters were again recorded after injection of induction drugs, after intubation, five minutes after intubation, just after pneumoperitoneum, and 5,10,15,30,45 and 60 minutes after pneumoperitoneum, five minutes after release of pneumoperitoneum, five and 10 minutes after extubation. Dexmedetomidine significantly attenuates stress response at intubation with lesser increase in HR (5% Vs 18%), SBP (9% Vs 19%) and DBP (3% Vs 15%), MAP (2% Vs 15%) as compared to fentanyl (p<0.05). Throughout intraoperative period of pneumoperitoneum Group D showed significant fall in HR, SBP, DBP, MAP from baseline value at all points of time intervals whereas it remained constantly high above baseline value in Group F (p-value <0.05). Dexmedetomidine when compared to fentanyl causes greater attenuation of stress response to tracheal intubation, following pneumoperitoneum and in intraoperative period resulting in greater reduction of HR, SBP, DBP, MAP than that of fentanyl, thus causing better haemodynamic stability in patients undergoing elective laparoscopic surgery.

Two Cases of EVAR for Hemodynamic Stable Patients of Fitzgerald Classification Grade 4 of Ruptured Iliac Artery Aneurysm and Abdominal Aortic Aneurysm

Two Cases of EVAR for Hemodynamic Stable Patients of Fitzgerald Classification Grade 4 of Ruptured Iliac Artery Aneurysm and Abdominal Aortic Aneurysm

English

INTRODUCTION: Anaesthesia has made major advances in recent years. Considerable efforts have been devoted to airway management by the anesthesiologist during the past 20 years. A large number of supraglottic airway devices have been introduced recently. The original purpose was to reduce the need for more invasive methods of airway management while offering a more reliable alternative to the facemask. The laryngeal mask airway (LMA) is one such innovative device designed for airway management. One of the principal aims of anaesthesia is to counter surgically induced stress. So the anesthesiologist should be able to use a method of delivering the anaesthetic that is by itself not stress inducing3. Since the LMA is placed directly over the posterior pharynx, it avoids tracheal stimulation and hence the systemic and ocular stress response associated with tracheal intubation. AIM OF THE STUDY: The aim of the study is to observe the usefulness of Midazolam and mini-dose of Succinyl choline to facilitate the insertion of laryngeal mask airway during Propofol anesthesia in elective general surgery patients based on the following parameters. 1. Conditions during insertion of laryngeal mask airway such as jaw relaxation, ease of insertion, number of attempts for insertion, airway trauma and total dose of Propofol. 2. Patient’s response to insertion of laryngeal mark airway such as gagging, coughing, head and limb movements, laryngospasm, etc. 3. Hemodynamic parameters like mean arterial pressure, heart rate and oxygen saturation. MATERIALS AND METHODS: After obtaining institutional ethical committee clearance and the patient consent, the study was carried out on 75 patients posted for elective surgical procedures lasting less than or equal to 45 min at Madras Medical College & GGH, Chennai. Patients belonging to the age group of 18 – 50 years of both the sexes were selected. Inclusion Criteria: 1. Elective short surgical procedures lasting less than or equal to 45 min Patients of ASA physical status I and II, 2. Aged between 18 – 50 years of both sexes. Exclusion Criteria: 1. Patients with full stomach ,pregnant patient, 2. Patients posted for emergency surgery, 3. Patients with oral, peri oral pathology such as tumours, abscess or grossly enlarged tonsils. OBSERVATIONS AND RESULTS: This study was conducted on 75 patients who were divided into 3 Groups of 25 patients each. Group A - Propofol Group, Group B - Propofol with midazolam Group, Group C - Propofol with succinyl choline Group. Demographic Profile: In group A and C, 48% of patients are males and rest 52% are females, while in group B 52% of patients are males and rest females. The mean age of patient is 30.52, 30.12 and 30.84 in groups A, B and C respectively. The mean weight is 51.8, 53 and 53.22 in groups A, B and C respectively. Patients in each group were statistically comparable in relation to sex, age and weight. SUMMARY: In this study, the conditions of LMA insertion, patient’s response to LMA insertion and the hemodynamic changes during and after LMA insertion in the following three groups of patients were observed. Group A - Inj. Propofol 2.5mg/kg only. Group B - Inj. Propofol 2.5 mg/kg + 0.04mg/kg midazolam. Group C- Inj. Propofol 2.5 mg/kg + 0.1 mg/kg succinyl choline. • The jaw relaxation was adequate in 100% of Group B patients compared to 32 % of patients in Group A and 64% in Group C. • Overall insertion conditions were excellent in 100% of patients in Group B compared to 32% in Group A and 44% in Group C. • LMA was inserted successfully in the first attempt in 100% of patients in Group A compared to 40% in Group A and 64% in Group C. • Airway trauma as evidenced by blood staining of LMA was found in 36% of patients in Group A and 32% in Group C while none of the patients in Group B had any airway trauma. • Post op myalgia was present in 40% of patients in Group C. • Patient movements were present in 48% of patients in Group A compared to 12% in Group C while no movement was present in any of the patient in Group B. • The total dose of Propofol required for successful insertion of LMA was 2.76mg/kg in Group A and 2.60 mg/kg in Group C, while it is the least 2.06mg/kg in Group B which is the cause of significant hemodynamic stability in patients of Group B CONCLUSION: To conclude, addition of Midazolam (0.04mg/kg) to the standard dose of propofol provides better LMA insertion conditions than the addition of mini-dose Succinyl Choline (0.1mg/kg).

Rate Control by Transoesophageal Atrial Overdrive Pacing for Refractory Supraventricular Tachycardia with Severe Ventricular Dysfunction: A Bridge to Recovery.

Tachyarrhythmia-induced cardiomyopathy (TIC) is a rare, yet life-threatening phenomenon in children. TIC has been defined as myocardial dysfunction that is entirely or partially reversible after control of the responsible tachyarrhythmia and is typically caused by an incessant supraventricular tachycardia. In cases of unsuccessful termination of the tachycardia, cardiogenic shock may occur. Several authors favour the use of mechanical circulatory support in such cases. Particularly with regard to these partly severe cases, the authors would like to present the option of transoesophageal overdrive pacing (TOP) as a tool for initial heart rate control and hemodynamic stabilization of patients with TIC refractory to conventional strategies of tachycardia termination. Chart review for patients receiving TOP during the last 5years in two centres was performed. A case series of successful TOP including technique and outcomes is depicted. Rate control through TOP is a safe and effective option to restore acceptable hemodynamics in infants with refractory supraventricular tachycardia and severe impairment of ventricular function. It presents the possibility of immediate heart rate control and offers time for myocardial recovery and safe implementation of antiarrhythmic drug therapy.

Is it safe to discharge blunt abdominal trauma patients with normal initial findings?

Background: Trauma is the leading health concern among young adults. Blunt abdominal trauma (BAT) is the most common type of blunt traumas. BAT patients may prove normal in the initial clinical assessments, but since the time required for an intra-abdominal injury to be clinically apparent is not predictable, deciding when to safely discharge these patients could be a dilemma. The purpose of this study is to determine whether follow-up of the early discharged or further diagnostic assessment of the later discharged BAT patients with normal initial findings reveals any abnormal findings.Methods: Totally, 389 hemodynamically-stable patients suspected of BAT who arrived at the emergency department (ED) of two university hospitals in Tehran from September 2013 to September 2014 were included in this study. Upon arrival at the ED, all subjects underwent abdominal examination and FAST, and were assessed for hematocrit and base deficit levels and presence of hematuria. These assessments were repeated in the patients who were discharged after 6 h, at 6 or 12 h post-arrival. All patients were followed-up after 24 h and one week by phone call.Results: Out of all study participants, 158 patients (40.6%) had normal findings in all initial assessments. These patients were discharged from the ED after a median of 5 h. After one week of follow-up, none of them had any symptom or complication, or had sought medical attention after being discharged from the study hospitals. Out of these patients, 78 patients (49.4%) were discharged after 6 hours by their physician’s decision, and underwent the same diagnostic assessments for the second or third time. None of these assessments revealed any abnormal findings.Conclusions: A combination of normal abdominal exam, normal FAST, normal hematocrit, normal base deficit, and absence of hematuria rules out intra-abdominal injury in BAT patients. It is safe to discharge patients after they prove normal for these assessments. Longer observation and repeated diagnostic assessment of these patients does not yield any new findings, and seems to be unnecessary.

Operative Management versus Conservative in Patients with Liver Trauma Injury

Background: The liver is one of the most frequently damaged organs when abdominal trauma occurs. Currently, conservative management becomes the treatment of choice in hemodynamic stable patients. Aim: To evaluate the results of an operative and conservative management of liver injury patients. Patients and methods: From March 2011 to June 2015, 113 patients suffered from hepatic trauma were referred to Zagazig University hospital, trauma unit. The patients were classified according to the way of management: Group I, operative management; Group II, conservative management. Variables analyzed included demographic data, injury classification, associated lesions, surgical treatment, morbidity, mortality, and hospital stay. Results: 113 patients had hepatic trauma. 39 (34.5%) patients were managed non- operatively. The commonest type of trauma was blunt and the main cause was motor vehicle in 59 (52.2%) patients. The second cause was stab injury with 33 (29.2%) patients. The least cause was gunshot injury in 21 (18.6%) patients. There was no significant difference in hospital stay between patients operated on and these managed non-operatively. There was no mortality in the patients managed conservatively. Conclusions: Conservative management is a safe approach for hemo-dynamically stable patients with liver trauma. Conservative management patients should be admitted to intensive care unit for at least 48-72 hours for close monitoring of vital signs repeated clinical examinations and follow up investigations as indicated. Failure of conservative treatment did not show a higher incidence of complications or mortality. Good results obtained from conservative management resulted from a highly cooperated trauma team including surgery, anethesia, intensive care, cardiothoracic and neurosurgery doctors.

Treatment of Complex Perineal Trauma. A Review of the Literature

Perineal injuries are uncommon, but not rare. They may present a wide variety of injury patterns which demand an accurate diagnostic assessment and treatment. Perineal injuries may occur as isolated injuries to the soft tissues or may be associated with pelvic organ, abdominal or even lower extremity injury. Hence the importance to know in depth not only the anatomy of the perineum and its organs, but also the implications of the patient's hemodynamic stability on the decision making process when treating these injuries using established trauma guidelines. The purpose of this review is to describe the current epidemiology and clinical presentation of perineal injuries in order to provide specific guidelines for the diagnosis and treatment of both stable and unstable patients.

Dexmedetomidine-fentanyl versus propofol-fentanyl in flexible bronchoscopy: A randomized study.

The aim of the present study was to evaluate the effect of a combination of dexmedetomidine and fentanyl on peripheral oxygen saturation (SpO2) and hemodynamic stability in patients undergoing flexible bronchoscopy. One hundred patients undergoing elective flexible bronchoscopy were randomized into either a propofol-fentanyl group (PF group; n=50) or a dexmedetomidine-fentanyl group (DF group; n=50). SpO2 values, heart rate (HR), systolic and diastolic blood pressure (SBP and DBP), patients' cough scores and discomfort scores as determined by patients and bronchoscopists, levels of sedation, number of times that additional lidocaine was required, elapsed time until recovery, and adverse events were recorded. The mean SpO2 values in the DF group were significantly higher than those in the PF group (P<0.01), and HR, SBP and DBP were significantly lower in the DF group than in the PF group (P<0.05). There were no statistically significant differences between the two groups in terms of cough scores or discomfort scores, sedation levels, or number of times that additional lidocaine was required (P>0.05). Elapsed time until recovery in the DF group was significantly longer than in the PF group (P=0.002). The incidence of hypoxemia was significantly lower in the DF group than in the PF group (P=0.027), but the incidence of bradycardia was significantly higher in the DF group than in the PF group (P=0.037). Dexmedetomidine-fentanyl was superior to propofol-fentanyl in providing satisfactory SpO2. Furthermore, dexmedetomidine-fentanyl attenuated hemodynamic responses during bronchoscopy and maintained hemodynamic stability in the early stage of the procedure.

Can adding Ephedrine to Admixture of Propofol &amp; Lidocaine Overcome Propofol Associated Hemodynamic Changes and Injection Pain?

Purpose: There are numerous studies researching ways to alleviate propofol injection pain. In this study, we evaluated and compared the use of propofol-lidocaine admixture vs propofol-lidocaine combined with ephedrine, on vascular pain and hemodynamic changes associated propofol. Methods: This double-blinded, prospective, randomised study was performed on 100 patients with ASA I-II who were divided into two group. The first received admixture consisting of 20 mg of lidocaine and propofol 1% 20 ml (Group L), and the other received admixture consisting of 20 mcg ephedrine, 20 mg lidocaine and propofol 1% 20 ml (Group LE). Baseline and after induction heart rate, mean arterial pressure and rate pressure product (RPP) were recorded per minute. Vascular pain were evaluated with verbal rating scale. Results: Data of 40 patients in group L and 39 patients in Group LE were evaluated in the study. The incidence of pain in group L was 90%, it was 38.4% for Group LE. Mild pain was observed significantly more in Group L when compared to Group LE (p<0.05). Average blood pressure and RPP immediately after induction and 1 min after intubation were signifi cantly higher in group LE compared to group L (p<0.05). Heart rate was higher in Group LE immediately after induction and at initially 4 minutes after intubation. Conclusion: Our study has demonstrated significant decrease in rate of vascular pain and increased hemodynamic stability in patients receiving 20 mg ephedrine added to 20 ml % 1 propofol and 20 mg lidocaine admixture when compared to those who only received the lidocaine-propofol admixture.

Tratamiento del trauma perineal complejo. Revisión de la literatura

Perineal injuries are uncommon, but not rare. They may present a wide variety of injury patterns which demand an accurate diagnostic assessment and treatment. Perineal injuries may occur as isolated injuries to the soft tissues or may be associated with pelvic organ, abdominal or even lower extremity injury. Hence the importance to know in depth not only the anatomy of the perineum and its organs, but also the implications of the patient's hemodynamic stability on the decision making process when treating these injuries using established trauma guidelines. The purpose of this review is to describe the current epidemiology and clinical presentation of perineal injuries in order to provide specific guidelines for the diagnosis and treatment of both stable and unstable patients.

Comparison of respiratory and hemodynamic stability in patients with traumatic brain injury ventilated by two ventilator modes: Pressure regulated volume control versus synchronized intermittent mechanical ventilation.

Background:This study aimed to compare pressure regulated volume control (PRVC) and synchronized intermittent mechanical ventilation (SIMV) modes of ventilation according to respiratory and hemodynamic stability in patients with traumatic brain injury (TBI) admitted to Intensive Care Unit (ICU).Materials and Methods:In a randomized, single-blinded, clinical trial study, 100 patients who hospitalized in ICU due to TBI were selected and randomly divided into two groups. The first and second groups were ventilated by PRVC and SIMV modes, respectively. During mechanical ventilation, arterial blood gas and respiratory and hemodynamic parameters were also recorded and compared between the two groups.Results:According to the t-test, the mean rapid shallow breathing index (RSBI) after the first 8 h of mechanical ventilation was significantly higher in SIMV group compared with PRVC group (107.6 ± 2.75 vs. 102.2 ± 5.2, respectively, P < 0.0001). Further, according to ANOVA with repeated measures, the trend of RSBI changes had a significant difference between the two groups (P < 0.001). The trend of ratio of partial pressure arterial oxygen and fraction of inspired oxygen was different between the two groups according to Mann–Whitney–Wilcoxon test (P < 0.001).Conclusions:Using PRVC mode might be more desirable than using SIMV mode in patients with TBI due to better stability of ventilation and oxygenating. To ensure for more advantages of PRVC mode, further studies with longer follow-up and more detailed measurements are recommended.

Effect of dexmedetomidine to attenuate the sympathetic response of laryngoscopy and intubation and perioperative hemodynamic stability in patients undergoing neurosurgery

Background and Aims: Dexmedetomidine is a selective α2 agonist used as an adjuvant to attenuate sympathetic response to laryngoscopy and tracheal intubation in general anesthesia. Recent studies have shown that dexmedetomidine decreases brain flow and cerebrospinal fluid pressure without cerebral ischemia. Hence, it is beneficial in neurosurgical procedures. This study was undertaken to analyze the efficacy of dexmedetomidine in neurosurgery for good perioperative hemodynamic stability with blunt sympathetic response to laryngoscopy and intubation. Materials and Methods: Sixty, American Society of Anesthesiologists grades II-IV patients between 18 and 50 years of age undergoing craniotomy under general anesthesia were divided randomly into two groups (thirty patients in each group). Group D: Dexmedetomidine was given as a bolus dose of 1 μg/kg diluted to a total volume of 20 ml with normal saline (0.9%) for 10 min before the induction of anesthesia. Group C: The patients received a similar volume of normal saline. Results: We observed a decrease in blood pressure and heart rate (HR) after intubation by dexmedetomidine, and they were highly significant on comparison (P Conclusion: Dexmedetomidine blunted the hemodynamic stress response due to laryngoscopy and intubation and perioperative hemodynamic stability in patients undergoing neurosurgery.

Relevance of using bispectral index monitoring to stabilize hemodynamic parameters in patients undergoing cardiac surgery under cardiopulmonary bypass by better titration of anaesthetic agents

Background:The aim of our study is to find the relevance of using a bispectral index (BIS) monitor, a neurophysiological monitoring device, in patients undergoing cardiopulmonary bypass and measure their hemodynamic stability due to better titration of anaesthetic drugs.Methods: After approval of the ethical committee and informed consents, forty patients were included in this study, age ranging between 45 and 60 years, of both sexes, scheduled for elective coronary bypass surgery or valve replacement done with cardiopulmonary bypass (CPB) were selected. This was a prospective, randomized, controlled study in which the subjects were randomly allocated into 2 groups of 20 each as per random number chart. They were (I) BIS monitor group (group A) where A the administration of propofol and isoflurane were controlled to achieve the target range of 40-60 BIS value and (II) BIS blinded to anaesthesiologist group (group B), where the BIS values were blinded to the anesthesiologist and the administration of propofol and isoflurane were left to the anesthesiologist's discretion.Results:Patient in group A had stable hemodynamic in that the incidence of fluctuation of blood pressure were only 15% while it was 80% in group B. Similarly the fluctuations in heart rate were 10% in group A and 75% in group B.Conclusions:By using Bispectral index monitor we can maintain a better hemodynamic stability in patients during cardiac surgery under cardiopulmonary bypass. This finding was in agreement to similar studies conducted by various researchers.

A comparative study of esmolol and dexmedetomidine on hemodynamic responses to carbon dioxide pneumoperitoneum during laparoscopic surgery.

Background:Carbon dioxide pneumoperitoneum for laparoscopic surgery increases arterial pressures, heart rate (HR), and systemic vascular resistance. In this randomized, single-blind, placebo-controlled clinical study, we investigated and compared the efficacy of esmolol and dexmedetomidine to provide perioperative hemodynamic stability in patients undergoing laparoscopic cholecystectomy.Methods:Sixty patients, of either sex undergoing elective laparoscopic cholecystectomy, were randomly allocated into three groups containing twenty patients each. Group E received bolus dose of 500 μg/kg intravenous (IV) esmolol before pneumoperitoneum followed by an infusion of 100 μg/kg/min. Group D received bolus dose of 1 μg/kg IV dexmedetomidine before pneumoperitoneum followed by infusion of 0.2 μg/kg/h. Group S (control) received saline 0.9%.Results:Mean arterial pressure and HR in Group E and D were significantly less throughout the period of pneumoperitoneum in comparison to Group S. IV nitroglycerine was required in 45% (9 out of 20) patients in Group S to control intraoperative hypertension, and it was clinically significant in comparison to Group E and D.Conclusion:Both esmolol and dexmedetomidine attenuate the adverse hemodynamic response to pneumoperitoneum and provide hemodynamic stability during laparoscopic surgery.

Conservative Management of Placenta Accreta by Systemic Metho-trexate: Report of Two Cases and Review of the Literature

Objective: Owing to the growing number of cesarean deliveries, the abnormally invasive placenta-tion so called placenta accreta rate is increasing. Placenta accreta is difficult to manage and traditionally resolved by cesarean hysterectomy after the birth due to the following massive hemorrhage. In recent years different conservative treatments leaving partially or totally the placenta in the uterine cavity have been reported in patients willing to preserve their fertility. Methods: We reviewed literature data about conservative management of placenta accreta in the PubMed, Researchgate and Medline from 2007 to date. We included in the review the studies about the use of methotrexate (MTX) for conservative treatment of placenta accreta. Results: We reported 2 literature reviews and 4 studies about the use of MTX in the management of placenta accreta and 2 unpublished cases treated in our Department. MTX is administered when it is not possible to remove totally or partly the placenta accreta in order to promote the cytolysis of the residual trophoblast. The schedule and outcome of the methotrexate use have not been established yet due to the paucity of literature data. Conclusions: The role of MTX to improve both, the feasibility and success rate of conservative management and placental resorption needs further studies. Hemodynamic stability of patients and informed consent are prerequisites before starting MTX treatment. Vaginal bleeding and infections may complicate the conservative treatment and close surveillance is recommended by imaging techniques and laboratory parameters.

A Comparative Study of Dexmedetomidine and Midazolam in Reducing Delirium Caused by Ketamine.

Ketamine is a well known agent for sedation for short surgical procedures due to its very good analgesic action. But it has cardio stimulatory response and recovery from anaesthesia after Ketamine use is complicated by delirium and hallucination. In studies it is proved that these side effects can be reduced by premedication with benzodiazepines. The α2 adrenoceptor agonists are becoming popular for their properties like haemodynamic stability and reducing anaesthetic requirement. This study was planned to see the effects of Dexmedetomidine on emergent reaction of Ketamine, when used as premedication agent with Ketamine for conducting short surgeries in adult patients. Study was conducted in 90 ASA class I and II male and female patients of age between 18-40 undergoing short procedures like laparoscopic ligation, skin grafting, dilatation and curettage, endoscopic procedures, excision of small swelling, etc. Patients were randomly divided into three groups of 30 each as follows: Group K: after premedication with inj. glycopyrrolate 0.01mg/kg, inj. Ketamine 2mg/kg, Group M: after premedication with inj. glycopyrrolate 0.01mg/kg and inj midazolam 0.05mg/kg, inj. Ketamine 2mg/kg, Group D: after premedication with inj glycopyrrolate 0.01 mg/kg and inj. Dexmedetomidine 0.5μg/kg, Ketamine 2mg/kg was given. Observations were made for cardiovascular response to invasive procedure, post anaesthetic anxiety and delirium with help of Memorial Delirium Assessment scale (MDAS). Midazolam reduced delirium to a greater level, but in comparison to control group and midazolam group, dexmedetomidine reduced delirium to a much greater level (p-value<0.001). Postoperative pain was less in Dexmedetomidine group (p-value< 0.001). Dexmedetomidine reduced delirium caused by Ketamine when used as a premedication agent. It produced more haemodynamic stable patients. Postoperative analgesia was also better.