A comparative study on monitored anesthesia care

A Historical Review of Indian Perspectives on Techniques of Tympanoplasty

Reconstructive surgery of the conductive hearing mechanism is collectively called as tympanoplasty, which has gradually evolved over time with the contributions from all over the word. The aim of the present historical review is to summarize the Indian contributions in the development of the technique of tympanoplasty. The literature review was conducted using only the “Medline” search using keywords “tympanoplasty” and “ossiculoplasty” in “India” on 15^th June 2016. A total of 195 articles and abstracts were found dated from the year 1998 onwards. Articles describing work on technique were included, and those describing only experimentation with graft material were excluded. All articles were fully read and analysed. It was found that there had been experiments regarding the choice of anaesthesia and the use of combinations of different chemical agents for this purpose. There were suggestions in favour of monitored anaesthesia care for the surgery in select patients. Surgeons expressed their perspectives on the time and conditions for the surgery, laterality of surgery, different types of incisions, use of endoscopes, graft placement techniques, ossicular replacements with autologous or allogenic grafts, and the timing of prophylactic antibiotic therapy given after or during the surgery. The range of work is wide and covers most of the aspects of surgery; however, the incorporation of a uniform methodology and standards reporting results were lacking in the articles reviewed.

A Cross-Sectional Pharmacoepidemiological Study of the Utilization Pattern of Pre-Anesthetic Medications in Major Surgical Procedures in a Tertiary Care Hospital

Objective 

A study of the utilization pattern of pre-anesthetic medications in major surgical procedures.

Material and methods 

A cross-sectional, pharmacoepidemiological study was conducted among patients undergoing surgical procedures in routine or emergency conditions under general anesthesia. The utilization of pre-anesthetic medicines in all patients was reported.

Results

A total of 110 patients (mean age - 42.36 years; 57.27% males) were enrolled. The major (>10%) indications for surgery were carcinoma/tumor - 25 (22.73%), perforation peritonitis - 20 (18.18%), and intestinal obstruction - 11 (10%). All patients received ranitidine plus metoclopramide. Injections of ondansetron, midazolam, pentazocin, anticholinergic agents, and fentanyl were used in 103 (93.64%), 103 (93.64%), 92 (83.64%), 84 (76.36%), and 23 (20.91%) patients, respectively. The dosage of ondansetron was 4 mg in 95 patients (86.36%), while 89.09% patients received 1 mg of midazolam. In 86 patients (78.18%), pentazocine was used in a 15 mg dose. Among the anticholinergic agents, glycopyrrolate was used in 76 patients (69.09%). Glycopyrrolate was used in a 0.2 mg dose in 74 patients (97.37%). The major indications for the use of fentanyl were carcinoma - 8 (34.8%), perforation peritonitis - 4 (17.4%), and surgery for intestinal obstruction - 3 (13%).

Conclusion

The administration of ondansetron, midazolam, and pentazocin is very common (>80% patients) as pre-anesthetic medication. Glycopyrrolate was the preferred anticholinergic agent. In cancer patients, the use of fentanyl is common.

Comparison of dexmedetomidine and propofol for conscious sedation in inguinal hernia repair: A prospective, randomized, controlled trial

Objective The ideal agents for conscious sedation during ambulatory inguinal hernia repair are still unclear. We aimed to compare the analgesic, sedative, haemodynamic, and side effects of dexmedetomidine with those of propofol in combination with fentanyl for conscious sedation in patients undergoing inguinal hernia repair. Methods Eighty patients undergoing unilateral inguinal hernia repair were prospectively randomized to receive either dexmedetomidine (n = 40) or propofol (n = 40). Dexmedetomidine and propofol dosages were adjusted to maintain the targeted level of sedation. Results After administration of sedative drugs, patients who received dexmedetomidine had a significantly lower heart rate. The intraoperative requirement of fentanyl was significantly lower in patients who received dexmedetomidine compared with patients who received propofol. Administration of dexmedetomidine was associated with a reduced postoperative pain score, longer time for onset of sedation, and a slightly longer recovery time. No serious adverse events occurred in either group. The patients' overall satisfaction score was comparable between the two groups. Conclusion Dexmedetomidine is an effective adjuvant when co-administered with fentanyl for conscious sedation in patients who undergo inguinal hernia repair. Administration of dexmedetomidine decreases the requirement of fentanyl and the pain score, but slightly prolongs the time to sedation and recovery.

Monitored anaesthesia care - Comparison of nalbuphine/dexmedetomidine versus nalbuphine/propofol for middle ear surgeries: A double-blind randomised trial

Background and Aims:

Middle ear surgeries (MESs) are usually performed under sedation with local anaesthesia and can be well tolerated by the patient with minimal discomfort. In the present study, we compare the effect of nalbuphine/dexmedetomidine combination with nalbuphine/propofol on sedation and analgesia in monitored anaesthesia care.

Methods:

One hundred adult patients undergoing MESs under monitored anaesthesia care (MAC) were randomly allocated into two groups. All patients in both groups received injection nalbuphine 50 μg/kg intravenously (IV). Group D received a bolus dose of injection dexmedetomidine 1 μg/kg IV over 10 min followed by an infusion started at 0.4 μg/kg/h IV. Group P received a bolus dose of injection propofol 0.75 mg/kg followed by an infusion started at 0.025 mg/kg/min IV. Sedation was titrated to Ramsay Sedation Score (RSS) of 3. Patient's mean arterial pressure, heart rate, saturation peripheral pulse and need for intraoperative rescue sedation/analgesia were recorded and compared. The data analysis was carried out with Z test and Chi-square test.

Results:

Mean RSS was significantly more in Group D (4.24 ± 1.54) as compared to Group P (2.58 ± 0.95). Overall VAS score was also significantly less in Group D (3.5 ± 1.7) than in Group P (5.4 ± 1.8). In total, 16 patients (32%) in Group D had hypotension whereas 7 patients (14%) only in Group P had hypotension.

Conclusion:

Nalbuphine/dexmedetomidine combination is superior to nalbuphine/propofol in producing sedation and decreasing VAS in patients undergoing MESs under MAC. Better surgeon and patient satisfaction were observed with nalbuphine/dexmedetomidine. Haemodynamics need to be closely monitored.

Comparison of remifentanil with dexmedetomidine for monitored anaesthesia care in elderly patients during vertebroplasty and kyphoplasty

OBJECTIVES

This clinical trial is registered at ClinicalTrials.gov. (NCT02476981)This randomized, prospective double-blind study compared remifentanil with dexmedetomidine for monitored anaesthesia care during minimally invasive corrections of vertebral compression fractures (vertebroplasty or kyphoplasty).

METHODS

Patients > 65 years of age with American Society of Anesthesiologists (ASA) classification I-III, scheduled for vertebroplasty or kyphoplasty under monitored anaesthesia care, received remifentanil (i.v. infusion 1-5 µg/kg/h) or dexmedetomidine (loading dose 0.3-0.4 µg/kg followed by i.v. infusion 0.2-1 µg/kg/h) to maintain observer's assessment of alertness/sedation (OAA/S) scale <4 during the procedure.

RESULTS

There were no statistically significant differences in demographic data between the remifentanil (n = 37) and dexmedetomidine groups (n = 38). Patients on dexmedetomidine experienced lower mean arterial pressure (MAP) and heart rate (HR), and higher SpO2 values, than patients on remifentanil. Compared with dexmedetomidine, remifentanil produced more respiratory depression, oxygen desaturation, and reduced the need for additional intraoperative opioids. There were no significant between-group differences in terms of recovery time, investigators' satisfaction scores, or patients' overall pain experiences.

CONCLUSIONS

During monitored anaesthesia care, dexmedetomidine provides less respiratory depression, lower MAP and HR, but also less analgesic effect than remifentanil in elderly patients undergoing vertebroplasty or kyphoplasty.