Reported Pain During Labour - A Qualitative Study of Influencing Factors among Parturient During Confinement in Private or Government Hospital

INTRODUCTION

Labour pain is distressing and it produces undue side effects both to the mother and the baby. The incidence is high in developing countries like India where the awareness about labour analgesia is still lacking.

AIM

It is to find out the incidence of labour pain and the influence of various described factors on pain with a comparison between patients admitted in a government set up with a private set up in a south Indian semi-urban area.

MATERIALS AND METHODS

Two hundred continuous uneventful normal deliveries each in a Government (group G) and a private hospital (group P) were enrolled for the study. The reported pain during labour was noted 6-7 hours after delivery by interacting with the patient. The factors like age of the mother, sex and weight of the baby, literacy, socioeconomic status, the use of oxytocics and analgesia were evaluated.

RESULTS

The incidence of severe pain was more in group G (43.5%) than group P (12%). There was no analgesic intervention in 68.5% in group G while it was 13.5% (27/200) in group P. Even among these 27 patients who did not receive analgesics, only three parturients reported severe pain. Even administration of analgesics in a Government set up did not decrease pain to a significant extent. There were richer and more literate patients in group P. Booked cases were less in group G. Logistic regression analyses to find out factors which influenced pain in either group was used. Gravida, analgesic intervention and admission in a Govt. hospital influenced the pain experience of the parturient. There was minimal antenatal preparation in both the groups. There were no post partum complications.

CONCLUSION

Mothers suffered from labour pain to a significant extent and there is an urgent need for awareness about labour analgesia. Primigravida, admission in a Govt. set up and analgesic interventions were the factors which influenced pain than others. Patients admitted in Govt. hospitals suffered more pain with less analgesic intervention possibly due to illiteracy. The increased drug intervention in Group P was just incidental and routine on their demand and did not correlate with pain. A sincere effort to increase antenatal counseling should be initiated.

Anaesthesia practice and reproductive outcomes: Facts unveiled

Background and Aims:

Anaesthetic practice is associated with a risk of chronic exposure to anaesthetic agents. With the advent of newer inhalational agents and changing anaesthetic practices, the risks for anaesthesiologists with regard to adverse reproductive outcomes is unknown. Hence, a nationwide online survey was conducted to study the anaesthetic practices prevalent in India and their association, if any, with poor reproductive outcomes.

Methods:

The online survey involved 9974 anaesthesiologists. A questionnaire soliciting information regarding anaesthetic practice techniques, reproductive outcomes and perinatal outcomes was designed. All the anaesthesiologists in the ISA National database were mailed a link to the above questionnaire.

Results:

Female anaesthesiologists and spouses of male anaesthesiologists had a higher incidence of first trimester spontaneous abortions than the general population. Female anaesthesiologists when compared with spouses of male anaesthesiologists faced more difficulty with conception (P = 0.015). Female anaesthesiologists who worked in the operating room (OR) in their first trimester of gestation had a higher incidence of spontaneous abortions than those who did not work in the OR (P = 0.05). Longer hours of general anaesthesia conducted in the first trimester of pregnancy was associated with a higher risk of birth defects in their progeny (P = 0.05).

Conclusion:

Spontaneous abortions and birth defects were higher in female anaesthesiologists who worked in the OR in the first trimester of gestation. Both female anaesthesiologists and spouses of male anaesthesiologists had a greater risk for a first trimester miscarriage than the general population.

Rapid and reliable smooth extubation - Comparison of fentanyl with dexmedetomidine: A randomized, double-blind clinical trial

BACKGROUND

Fentanyl and dexmedetomidine have been tried to attenuate airway and circulatory reflexes during emergence and extubation individually but have not been compared with respect to the level of sedation to evolve a reliable technique for rapid and smooth extubation.

AIM

To compare the effects of fentanyl and dexmedetomidine in attenuating airway and circulatory reflexes during emergence and extubation of the endotracheal tube.

SETTING AND DESIGN

This double-blind, randomized, controlled study was done in patients undergoing surgery under general anesthesia belonging to the American Society of Anesthesiologists physical status 1 or 2.

METHODOLOGY

All patients received a standardized anesthetic protocol. Patients were randomized to receive either fentanyl 1 μg/kg or dexmedetomidine 0.75 μg/kg. Fifteen minutes before expected last surgical suture, isoflurane was cutoff and equal amount of test solution was given when train-of-four ratio was 0.3. The degree of sedation, airway, and circulatory responses at the time of suction and extubation were analyzed.

STATISTICAL ANALYSIS USED

Chi-square test for nonparametric data and t-test for parametric data.

RESULTS

Heart rate (HR) was comparable in both the groups until endotracheal extubation. Later, there was rise in HR in fentanyl group. There was stastisticaly significant drop in blood pressure at 5 min after test drug administration in both the groups. Airway response for suctioning and extubation was better in dexmedetomidine group and it was associated with better sedation score than fentanyl group.

CONCLUSION

Single dose of 0.75 μg/kg dexmedetomidine given 15 min before extubation provides smooth extubation when compared to fentanyl.

Role of temporary pacing at the right ventricular outflow tract in anesthetic management of a patient with asymptomatic sick sinus syndrome

A 60-year-old woman posted for percutaneous nephrolithotomy with ureterolithotripsy was found to have a history of hypertension and ischemic heart disease from past 6 months on regular treatment. Pulse rate was irregularly irregular in a range of 56–60/min, unresponsive to atropine, with a sinus pause on the electrocardiogram. Although the patient was asymptomatic, anticipating unmasking of the sick sinus syndrome during general anesthesia in the prone position, a temporary pacemaker was implanted at right ventricular outflow tract (RVOT) septum before the scheduled surgery. A balanced anesthesia technique with endotracheal intubation was administered. There were several episodes of continuous pacing by the temporary pacemaker intraoperatively, which may be attributed to unmasking of the sinus node dysfunction due to general anesthesia. At the end of surgery, patient was extubated after adequate reversal from neuromuscular blockade. Postoperative period remained uneventful, and the pacemaker wires were removed on the 2^nd postoperative day. With this case report, we highlight the importance of inserting a temporary pacemaker prior to anesthesia even in an asymptomatic patient if a sinus node dysfunction is suspected preoperatively and if intraoperative access to transvenous pacing is difficult such as in prone position. Pacing at RVOT septum minimizes ventricular dyssynchrony and improves hemodynamic parameters.

Comparison of dexmedetomidine and clonidine as an adjuvant to ropivacaine for epidural anesthesia in lower abdominal and lower limb surgeries

BACKGROUND

The quality and duration of analgesia is improved when a local anesthetic is combined with alpha 2 adrenergic agonist. Though, the effects of clonidine on local anesthetics have been extensively studied, there are limited studies demonstrating the effects of epidural dexmedetomidine on local anesthetics. The aim of our study is to compare the effect of clonidine and dexmedetomidine when used as an adjuvant to epidural ropivacaine in lower abdominal and lower limb surgeries.

MATERIALS AND METHODS

Patients were randomized into two groups-group ropivacaine with clonidine (RC) received 15 ml of 0.75% ropivacaine with 1 μg/kg clonidine and group ropivacaine with dexmedetomidine (RD) received 15 ml of 0.75% ropivacaine with 1 μg/kg dexmedetomidine epidurally. Onset of sensory analgesia using cold swab, onset of motor blockade using Bromage scale, time to 2 dermatome regression of sensory level, time to first demand for analgesia, sedation using Ramsay sedation scale, intra operative hemodynamic parameters and complications were assessed.

RESULTS

The onset (RD-8.53 ± 1.81, RC-11.93 ± 1.96) and duration of sensory blockade (RD-316 ± 31.5, RC-281 ± 37, sedation were found to be significantly better in the dexmedetomidine group. No significant difference was found in terms of onset of motor blockade and hemodynamic changes.

CONCLUSION

Dexmedetomidine at doses of 1 μg/kg is an effective adjuvant to ropivacaine for epidural anesthesia, which is comparable to clonidine.

An Effective Edge and Texture Based Approach towards Curved Videotext Detection and Extraction

In present day video text greatly helps video indexing and retrieval system as they often carry significant semantic information. Video text analysis is challenging due to varying background, multiple orientations and low contrast between text and non-text regions. Proposed approach explores a new framework for curved video text detection and recognition where from the observation that curve text regions can be well defined by edges size and uniform texture, Probable curved text edge detection is accomplished by processing wavelet sub bands followed by text localization by utilizing fast texture descriptor LU-transform. Binarization is achieved by maximal H-transform. A Connected Component filtering method followed by B-Spline curve fitting on centroid of each character vertically aligns each oriented character. The aligned text string is recognized by optical character recognition (OCR). Experiments on various curved video frames shows that proposed method is efficacious and robust in detecting and recognizing curved videotext.

Estimation of effect-site concentration of propofol for laryngeal mask airway insertion using fentanyl or morphine as adjuvant

BACKGROUND AND AIMS

Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides jaw relaxation and suppression of upper airway reflexes. Propofol can provide these conditions especially when combined with narcotics. This study had been designed to find out the effect-site concentration (EC50) of propofol using target controlled infusion (TCI) when fentanyl or morphine is added as an adjuvant.

METHODS

Patients satisfying inclusion criteria were divided into fentanyl and morphine groups. Intravenous glycopyrrolate 0.2 mg was given 15 min before induction. Patients were given either intravenous fentanyl (1 μg/kg) or morphine (0.1 mg/kg) before propofol infusion depending on the group. Patients in either groups were induced by continuous infusion of propofol at an EC of 6 μg/mL by TCI with Schneider pharmacokinetic model. The LMA supreme of appropriate size was inserted 1 min after achieving target concentration. Patient movement at LMA insertion or within 1 min of insertion was classified as failure. For subsequent patients, the target EC was increased/decreased depending on previous patients' response. Dixons up and down method was used to determine the EC50. The EC50 is defined as the mean of crossover midpoints in each pair of failure to success.

RESULTS

The EC50 of propofol in the fentanyl group for LMA insertion was 5.95 ± 0.6 μg/ml and morphine group was 5.75 ± 0.8 μg/ml. No significant difference in insertion conditions was noticed between the two groups (P = 0.3).

CONCLUSION

We conclude that there was no significant difference in propofol EC50 for insertion of LMA and insertion conditions were similar when fentanyl or morphine was used as an adjuvant drug.

Anesthetic management of a patient presenting with eclampsia

Eclampsia is one of the most common emergencies encountered by anesthesiologists which involve a safe journey of two lives. The definition, etiology, pathophysiology, treatment guidelines along with a special reference to management of labour pain and caesarean section are discussed. Eclampsia is commonly faced challenging case in our day to day anaesthesia practice,but less is discussed in our anaesthesia text books. Lot of controversies with regard to fluid management and monitoring still remain unanswered

Bilateral vocal cord edema following anterior cervical discectomy-usefulness of bonfils retromolar fiberscope

We present a case of a 40-year-old male patient who presented to us with radicular pain in arm for anterior cervical discectomy with fusion. The preanesthetic checkup including indirect laryngoscopy was normal with routine investigations within normal limits. The patient was induced and intubated with the established routine technique without any obvious airway problems. Prophylactic dexamethasone was administered, and the intraoperative course was uneventful. Immediately after extubation, it was noticed that the patient had inspiratory stridor and whispered voice on the operation theater table itself. Assessment by Bonfils retromolar fiberscope under fentanyl sedation revealed bilateral vocal cord edema. The patient was re intubated and put on T piece with humidified O2. After 72-h, patient was extubated after confirming normal vocal cord movement under flexible fiberscope guidance. This case is presented to alert anesthesiologist about the possibility of vocal cord edema even though other potential airway complications are possible. We would also highlight the importance of Bonfils retromolar fiberscope in awake vocal cord examination and flexible fiberscope use in managing patients presenting with airway problems during extubation.

Continuous spinal anesthesia with epidural catheters: An experience in the periphery

Background and Aim:

Continuous spinal anesthesia (CSA) offers considerable advantages over “singleshot” spinal or epidural anesthesia since it allows administration of well-controlled anesthesia using small doses of local anesthetics and a definite end point with less failure rate. There are described technical difficulties with introduction of spinal micro catheters and hence this study was undertaken by using epidural catheters.

Materials and Methods:

Sixty patients of ASA grade II to III were selected and they were administered continuous spinal anesthesia with Portex 18-G epidural catheters.

Results:

The introduction was done in first attempt and was easy in all cases. The intraoperative period was uneventful in all cases. Early postoperative analgesia was achieved in all cases. Only two patients (3%) had postdural puncture headache controlled with simple analgesics. In a 3 month postoperative followup, the incidence of neurological complication is nil.

Conclusion:

We conclude CSA with epidural catheters is a simple and safe alternative for prolonged procedures with negligible failure rate especially in high-risk patients and in patients with possible difficulties in administration of general anesthesia.

A comparative study between Truview(PCD) laryngoscope and Macintosh laryngoscope in viewing glottic opening and ease of intubation: A crossover study

Background:

Truview^PCD laryngoscope is specially designed to aid positioning of the endotracheal tube as well as to record entry of the tube into glottis. Aim of the study is to compare the view of glottic opening and ease of intubation between Truview^PCD laryngoscope and Macintosh laryngoscope in patients undergoing general anesthesia (GA).

Methodology:

Two hundred patients undergoing elective surgery, under GA were randomized into two groups, Group TV and Group ML. In Group TV, Trueview^PCD laryngoscope was used initially to visualize the vocal cords for Cormack and Lehane grading (CLG) and to spray the vocal cords with 10% lignocaine. Then the patient was ventilated for 1 min and Macintosh laryngoscope was used to visualize the vocal cords for CLG and proceed with intubation. In Group ML, Macintosh laryngoscope was used initially and later Truview^PCD laryngoscope. Time to intubation, CLG, number of attempts and hemodynamic parameters were recorded.

Results:

Ninety-six and 89 patients had CLG1 visualization when Truview^PCD laryngoscope was used as 1^st and 2^nd device respectively compared to 41 and 68 with Macintosh laryngoscope (P = 0.00). Four patients had CLG 4 visualization with Macintosh laryngoscope that turned out to be grade II visualization with Truview^PCD laryngoscope (P = 0.00). Mean time taken for intubation with Truview^PCD and Macintosh laryngoscope was 21.10 ± 5.64 s and 15.79 ± 2.76 s respectively (P = 0.00).

Conclusion:

Better visualization with lesser CLG was found with Truview^PCD laryngoscope but it took longer time for intubation than Macintosh laryngoscope. The hemodynamic response to intubation was significantly less with the use of Truview^PCD laryngoscope when compared to that of Macintosh laryngoscope.

Comparison of efficacy of three subanesthetic doses of ketamine in allaying procedural discomfort during establishment of subarachnoid block: A randomized double-blind trial

Background:

Procedural discomfort is experienced by patients during the establishment of subarachnoid block even after good preoperative counseling and adequate premedication. To enhance comfort, procedural sedation that would provide good analgesia, faster recovery, and amnesia is necessary.

Materials and Methods:

Patients with American Society of Anesthesiologists Status I and II posted for elective surgeries under subarachnoid block were premedicated with injection midazolam 0.05 mg/kg and preloaded with 10 ml/kg ringer lactate solution. They were randomized into three groups of 30 each. Group K0.3 received ketamine 0.3 mg/kg, Group K0.4 received ketamine 0.4 mg/kg and Group K0.5 received ketamine 0.5 mg/kg intravenously. University of Michigan sedation score, ease of positioning, prick response, verbal response, hallucinations, recall of procedure, and patient satisfaction were evaluated.

Results:

There was statistically significant difference in sedation among the three groups. Increased dose necessitated help of two persons to position the patient, which showed statistically significant difference. Verbal response was seen early in Group K0.3 (4.67 ± 2.84 min). There was no recall of experience of subarachnoid block procedure in any of the groups in spite of back muscle contraction or patient movement. Hence, all patients in all three groups were satisfied and were willing to undergo subarachnoid block, if the situation arises.

Conclusion:

Ketamine in the dose of 0.3 mg/kg provided sufficient sedation for allaying procedural discomfort due to less sedation, less positional difficulty, early verbal response, no hallucinations, no recall of performance of procedure, and good patient satisfaction.

Ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs in patients who receive mechanical ventilation (MV). According to the International Nosocomial Infection Control Consortium (INICC), the overall rate of VAP is 13.6 per 1,000 ventilator days. The incidence varies according to the patient group and hospital setting. The incidence of VAP ranges from 13-51 per 1,000 ventilation days. Early diagnosis of VAP with appropriate antibiotic therapy can reduce the emergence of resistant organisms.

METHOD

The aim of this review was to provide an overview of the incidence, risk factors, aetiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. This review outlines VAP's risk factors, diagnostic methods, associated organisms, and treatment modalities.

CONCLUSION

VAP is a common nosocomial infection associated with ventilated patients. The mortality associated with VAP is high. The organisms associated with VAP and their resistance pattern varies depending on the patient group and hospital setting. The diagnostic methods available for VAP are not universal; however, a proper infection control policy with appropriate antibiotic usage can reduce the mortality rate among ventilated patients.

Role of Appropriate Therapy in Combating Mortality among the Ventilated Patients

CONTEXT

Ventilator associated pneumonia (VAP) is a nosocomial infection prevalent among the intensive care unit (ICU) patients despite proper infection control practices. The diagnosis of VAP still remains controversial and hence the mortality rate is higher among this group of patients.

AIM

The aim of our study was to identify the antibiotic pattern and the appropriateness of treatment followed in the ICU in relation with the clinical pulmonary infection score (CPIS) as a tool to diagnose VAP. This was compared with patients who had an inappropriate treatment in comparison to the CPIS and the clinical outcome.

RESULTS

Out of the 18 VAP patients, 12 (66.7%) received appropriate therapy based on the antibiotic susceptibility pattern of the causative organism, while 1 (5.5%) received partially inappropriate therapy and 5 (27.8%) received totally inappropriate therapy. Nine of the 18 (50%) VAP patients died, while only 5 of the 58 (8.6%) patients without VAP died. 72.2% patients with VAP received appropriate treatment based on the sensitivity of the isolates. The mortality rate in VAP patients receiving inappropriate therapy was 80%, while in those receiving appropriate therapy the mortality rate was 38.5%. The mortality rate among VAP patients with blood culture positivity was 100%, while it was 43.75% among those with negative blood culture.

CONCLUSION

The mortality rate among the patients receiving inappropriate therapy is high compared to other group of patients. Hence, a proper evaluation and administration of appropriate antibiotics can curb mortality among the ventilated patients.

Study of patient satisfaction and self-expressed problems after emergency caesarean delivery under subarachnoid block

BACKGROUND AND AIMS

Subarachnoid block is one of the common modes of anaesthesia opted for emergency caesarean section, if the maternal and foetal conditions are favourable. Various factors influence the quality of care administered during the procedure. This questionnaire based study was undertaken to look for self-expressed problems in peri-operative period in patients undergoing emergency caesarean surgery under subarachnoid block.

METHODS

All the parturients who underwent emergency caesarean section under subarachnoid block during 6 months period were distributed a questionnaire in post-operative period. They were encouraged to fill and return the form within 15 days. Patient satisfaction and the self-expressed problems were analysed at the end of 6 months.

RESULTS

One hundred and seventy five out of 220 parturients responded. 58.3% of them said that they were explained about the anaesthesia prior to surgery and 85.3% overall remained anxious. With people around them, 93.1% of them felt comfortable and 91.4% expressed that they were made comfortable inside the theatre. The self-expressed problems were shivering (43.4%), breathlessness (21.7%), pain (20%), post-operative headache (15.4%) and backache (19.4%). Parturients who heard their babies cry was 85.1%. After their babies were shown after delivery, 77.1% mothers slept well; 86.9% fed their babies within 4 h of delivery.

CONCLUSION

Pre-operative communication in emergency caesarean section by health personnel did not reduce the anxiety level, which shows that communication was ineffective. Intra-operative psychological support like making the patient comfortable, showing baby to mother and early breast feeding improve bonding between child and mother and essentially contribute to patient satisfaction.

Aetiological agents of ventilator-associated pneumonia and its resistance pattern - a threat for treatment

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common type of nosocomial pneumonia encountered in intensive care units. There are several aetiological agents which make treatment challenging. Improper antibiotic treatment of ventilated patients may lead to the emergence of multidrug resistant (MDR) pathogens.

METHOD

A prospective study was performed over a period of 20 months. Our study had two arms: the first, 'Incidence and risk factors of VAP in a tertiary care hospital' was the subject of an earlier publication; we therefore present the second investigative arm in this work. The aetiological agents of patients on mechanical ventilation (MV) were identified by standard bacteriological method. The susceptibility pattern was evaluated by Kirby-Bauer disc diffusion method. Extended spectrum beta lactamase (ESBL) testing was performed by combination disc method, and metallo-beta lactamase (MBL) testing was performed by EDTA disk synergy test (EDS).

RESULTS

Late-onset VAP was associated with Pseudomonas aeruginosa, Klebsiella pneumoniae and Escherichia coli, while early-onset VAP was commonly caused by members of Enterobacteriaceae, Candida albicans and Staphylococcus aureus. 72.2 per cent of VAP patients had monomicrobial and 27.8 per cent had polymicrobial infection. Out of the 24 isolates obtained from patients with VAP, seven (29.2 per cent) were MDR pathogens. ESBL and MBL production was detected in 40 per cent and 20 per cent of Klebsiella pneumoniae isolated in our study. Around 50 per cent of isolates associated with late-onset VAP were MDR, while 22.2 per cent isolates obtained from patients with earlyonset VAP were MDR.

CONCLUSION

VAP is a nosocomial pneumonia that is common among ventilated patients. The aetiological agents vary from common organisms to MDR pathogens that are difficult to treat. A proper knowledge of MDR pathogens and early isolation followed by prevention of prolonged antibiotic therapy can reduce the mortality of late onset VAP.