Comparison of the efficacy of intranasal atomised dexmedetomidine versus intranasal atomised ketamine as a premedication for sedation and anxiolysis in children undergoing spinal dysraphism surgery: A randomized controlled trial

BACKGROUND

Preoperative anxiety leads to adverse clinical outcomes and long-term maladaptive behavioural changes. The role of intranasal atomised dexmedetomidine and atomised ketamine as premedication to produce sedation and anxiolysis in paediatric neurosurgical patients has not been extensively studied.

OBJECTIVE

To study the efficacy of intranasal atomised dexmedetomidine and intranasal atomised ketamine as premedication in producing sedation and facilitating smooth induction in children undergoing spinal dysraphism surgery.

DESIGN

A prospective randomised double-blind trial.

SETTING

A tertiary teaching hospital.

PATIENTS

Sixty-four children aged 1 to 10 years undergoing spinal dysraphism surgery.

METHODS

Children were randomised to receive intranasal atomised dexmedetomidine 2.5 μg kg -1 (Group D, n  = 32) and intranasal atomised ketamine 5 mg kg -1 (Group K, n  = 32) 30 min before surgery.

OUTCOMES MEASURED

The primary outcome was to compare the level of sedation in both groups using the University of Michigan Sedation Score (UMSS). The secondary outcomes included an assessment of the ease of parental separation, intravenous cannulation and satisfactory mask acceptance along with perioperative vitals (heart rate, blood pressure and oxygen saturation). The incidence of emergence agitation and time to discharge were also noted.

RESULTS

The degree of sedation was significantly better in Group D as compared to Group K at 20 min (UMSS, 1.55 ± 0.51 versus 1.13 ± 0.34, difference, -0.406; 95% CI, -0.621 to -0.191; P  = 0.0001) and 30 min (2.32 ± 0.6 versus 1.94 ± 0.50, difference, -0.374; 95% CI, -0.650 to -0.100; P  = 0.007). The ease of parental separation, venous cannulation and mask acceptance ( P  = 0.83, 0.418 and 0.100 respectively) were comparable in both groups. The heart rate was lower in group D at 10, 20 and 30 min post-drug administration but was clinically insignificant. The incidence of emergence agitation and time to discharge was also similar with no adverse events reported.

CONCLUSION

Intranasal atomised dexmedetomidine produces greater sedation as compared to intranasal atomised ketamine with comparable ease of parental separation, venous cannulation and mask acceptance with no adverse effects.

Comparison of Intraoperative Low-Dose Ketodex and Fentanyl Infusion for Postoperative Analgesia In Spine Surgery: A Prospective Randomized Double-Blind Study

STUDY DESIGN

Prospective randomized double-blind study.

PURPOSE

To assess the analgesic effects of the combination of a low-dose ketamine and dexmedetomidine (ketodex) infusion and compare it with that of fentanyl for postoperative analgesia after spine surgeries.

OVERVIEW OF LITERATURE

Adequate pain management following spine surgeries is crucial. Approximately 57% of patients experience inadequate pain control in the first 24 hours following elective spine surgery, which is attributable to the extensive soft tissue and muscle damage.

METHODS

The study included 60 patients graded American Society of Anesthesiologists I and II and scheduled for thoracolumbar spine surgery involving >3 vertebral levels. The patients were divided into two groups: group KD (ketodex) and group F (fentanyl). The primary objective was to compare the postoperative analgesic requirements among the groups. The secondary objectives included a comparison of the intraoperative anesthetic requirements, postoperative pain scores, hemodynamic parameters, side effects of the study drugs, and the duration of post-anesthesia care unit stay of both the groups.

RESULTS

Ketodex use prolonged the mean time to first rescue analgesia (22.00±2.30 hours vs. 11.69±3.02 hours, p <0.001) and reduced the requirement of rescue analgesics in the first 24 hours postoperatively compared to fentanyl use (70.00±8.16 μg vs. 113.31±36.65 μg, p =0.03). The intraoperative requirement of desflurane was comparable between the groups (p >0.05). The postoperative pain scores were significantly lower in the group KD than in group F at most timepoints (p <0.05). Patients in group KD had a shorter post-anesthesia care unit stay than group F did (p <0.001).

CONCLUSIONS

Low-dose ketodex could be a safe substitute for fentanyl infusion when employed as an anesthetic adjuvant for patients undergoing thoracolumbar spine surgeries involving >3 vertebral levels to achieve prolonged analgesia without any opioidrelated side effects.

Intermittent peri-tubal instillation of dexamethasone and ropivacaine on postoperative analgesia after percutaneous nephrolithotomy: A prospective randomized controlled trial

OBJECTIVES

Percutaneous nephrolithotomy and placement of nephrostomy tube are performed for renal stones >2 cm in diameter. Attempts have been made to infiltrate local anesthetics with or without adjuvants into the surgical site to reduce pain. We hypothesized that there would be a significant prolongation of the analgesic effect of local anesthetic instillation along the nephrostomy tube due to the adjuvant dexamethasone.

METHODS

After ethical approval and Clinical Trials Registry - India registration (CTRI/2020/03/024332), 64 American Society of Anesthesiologists classification 1 and 2 adult patients were enrolled in this randomized double-blinded prospective study divided into Group R-received 20 mL 0.2% Ropivacaine and Group R + D-received 20 mL 0.2% Ropivacaine with dexamethasone 8 mg, injected through a multi-lumen wound infiltration catheter.

RESULTS

The demographic profile of patients was similar in both groups. The mean duration of analgesia was longer in Group R + D (21.3 ± 2.1 hrs) versus Group R (10 ± 1.9 hrs, P = 0.001). The mean numeric rating scale scores of Group R + D were significantly lower at all time intervals (P = 0.001). Also, the cumulative dose of ropivacaine and the total use of fentanyl postoperatively in Group R was much higher (70 ± 10.4 vs 56 ± 8.9 μg, P = 0.02). The C-reactive protein levels were significantly lower in Group R + D (13.8 ± 1.5 vs 23.1 ± 1.2 mg/L, P = 0.001 and 16.5 ± 1.3 vs 28.5 ± 1.7 mg/L, P = 0.001, at 24 and 48 hrs, respectively).

CONCLUSION

We conclude that dexamethasone can be used as a suitable adjuvant to intermittent local anesthetic infiltration after percutaneous nephrolithotomy with a nephrostomy tube for the prolongation of analgesia.

Quantitative Assessment of Nitrous Oxide Levels in Room Air of Operation Theaters and Recovery Area: An Observational Study

Background:

Nitrous oxide has been used during surgical anesthesia for many years. However, information about occupational exposure and related risks due to N₂O exposure to the health care personnel in India are still poorly understood. Here, we measured the residual N₂O levels during the working time of operation theatre room air in our tertiary care hospital.

Material and Methods:

The air samples were collected from different anesthesia exposure zones on different days for quantitative analysis of available N₂O in the room air in respective areas. Nitrous oxide concentrations in the ambient air were also measured to compare outdoor and indoor levels.

Observations and Results:

Nitrous oxide mixing ratios were found to be 65.61 ± 0.05 ppm, 281.63 ± 0.43 ppm, and 165.42 ± 0.42 ppm in elective surgical theatres of the hospital on three different days whereas in emergency operation theatres of the same hospital levels of N₂O were 166.75 ± 0.07 ppm, 510.19 ± 0.30 ppm and 2443.92 ± 0.64 ppm during same period. In elective pediatric surgical theatres levels of N₂O were found to be 1132.55 ± 0.70 ppm and 362.21 ± 0.13 ppm on two days of reading respectively. Outdoor levels of N₂O in contrast found 0.32 ± 0.01 ppm and was lower by a factor of 1000.

Conclusion:

We observed the very high ambient concentration of N₂O in the surgical theatre's environment (up to 2443 ppm) and recovery areas (up to 50 ppm). It was 5 to 50 times higher ambient concentration of N₂O than REL in OT area and 200-7000 times higher ambient concentration of N₂O than outdoor ambient air in all surgical theaters other than CTVS OTs.

No Traces of SARS-CoV-2 In Wounds of COVID-19 Positive Patients: A Pilot Study

Background  This study was performed to investigate the presence of SARS-CoV-2 virus in wounds of COVID-19 positive patients. Methods  This is a single-center observational study. COVID-19 patients with wounds (traumatic/infective/surgical) were included in this study. Preoperative, intraoperative, or postoperative specimens were collected and analyzed with real-time reverse transcriptase polymerase chain reaction (rRT-PCR) to know the presence of the virus. Results  A total of eight patients were included in this study. Eleven samples were collected (seven wound swabs, two peritoneal fluids, and two tissue specimens) and analyzed. None of the samples from the wound tested positive for the virus while they were tested positive for nasal swab taken simultaneously or within 3 days prior. Conclusion  The wounds of COVID-19 patients are considered negative and can be managed with routine wound precautions.

Effects of low- and high-pressure carbon dioxide pneumoperitoneum on intracranial pressure during laparoscopic cholecystectomy

BACKGROUND

Laparoscopic surgeries are a risk factor for raised intracranial **pressure and neurological complications. Even though rare, the consequences may be severe.

METHODS

One hundred and one patients of laparoscopic cholecystectomy were enrolled and were randomized into two groups: low-pressure 8 mm Hg (Group A) and high-pressure 14 mm Hg (Group B) carbon dioxide pneumoperitoneum during surgery. Fifty patients were in group A and 51 patients were in group B. Intracranial pressure was measured by measuring the optic nerve sheath diameter (ONSD) using ultrasound examination. Baseline ONSD was recorded followed by ONSD recording at various intervals: at the induction of anesthesia; 30 min, 45 min, at the end of surgery; and 30 min post surgery.

RESULTS

The groups were comparable in terms of demographics and comorbidities. The mean age of group A was 45 years and for group B it was 45.75 years. Most common indication for surgery was symptomatic gall stone disease. Baseline ONSD in group A was 0.427 ± 0.0459 mm, whereas it was 0.412 ± 0.0412 mm in group B. There was a significant rise of ONSD (p < 0.05) 30 min after induction of pneumoperitoneum and up to 30 min post anesthesia. In the low-pressure group 7 (14%) patients had a significant rise of ICP, whereas in the high-pressure group 20 (39%) patients had a significant rise of ICP (p < 0.05).

CONCLUSIONS

High-pressure pneumoperitoneum causes significant rise in intracranial pressure in comparison to low-pressure pneumoperitoneum during laparoscopic cholecystectomy, which can be monitored by ONSD measurement by ultrasound examination and is totally non-invasive.

Retrospective analysis of prognostic factors in dengue infected patients with intracranial bleed

BACKGROUND

Dengue is one of the most common mosquito-transmitted arboviral disease of tropical and a few subtropical areas in the world. It is estimated that approximately 100 million cases occur per year and approximately 2.5 billion people are at risk of developing dengue infection. Hemorrhagic complications causing encephalopathy are quite rare but fatal consequences of this deadly disease. This study was conducted to discuss the prognostic factors in the management of intracranial hemorrhage in dengue infected patients.

METHODS

This retrospective study was conducted in the neurosurgery department of our tertiary healthcare centre. Duration of the study was 1 year, and 18 patients who presented with intracranial bleed and required neurosurgical care were included in this study. All patients had deranged coagulation profile and were thrombocytopenic. All the patients were given platelet concentrates for correction of thrombocytopenia. Eight of these patients had deterioration in their neurological status, and 6 of them underwent surgery.

RESULTS

Out of 18 patients, 12 (66.66%) were managed conservatively, including one case of cervical extradural hemorrhage. Five patients who were conservatively managed died because they had deep-seated bleed and rapid deterioration. The remaining 7 patients who were managed conservatively improved well with few residual deficits. Six (33.33%) patients who underwent surgery had excellent outcome with one case of mortality.

CONCLUSION

Very high index of suspicion is required in dengue infected patients for neurological complications, especially during the convalescence period. Special attention should be given to those patients who have altered sensorium, and should not be misinterpreted as fever delirium or toxic encephalopathy. It requires immediate attention and further neurological investigation (including thorough clinical examination). Timely diagnosis using a computed tomography scan and early neurosurgical intervention after rapid correction of thrombocytopenia can save many lives.

Spontaneous Postpartum Subacute Subdural Hematoma: A Case Report of Probable Compilation of Eclampsia

The author presents a patient who developed a subacute subdural hematoma approximately 2 weeks after normal delivery with history of postnatal convulsion and lateralizing neurological symptoms. On day 12, she started to feel a nonpostural and severe throbbing headache with motor aphasia and right hemiparesis power grade 4, she was referred to our department. Left subacute subdural hematoma was confirmed by a computed tomography scan. Physical examination revealed only mild right hemiparesis. Left burr hole trepanation was performed and this was followed by uneventful postoperative course, and it completely recovered after 4 weeks. Chronic subdural hematoma should be considered when postpartum patients who have history of ecclampsia with mild to severe, persistent, and non-postural headache.Nepal Journal of Neuroscience. Vol. 13, No. 2, 2016, Page: 109-111

Peri-operative Considerations in Intracranial Hemorrhage in Dengue Virus Infected Patients: A Prospective Mini Case Series

Dengue is one of the most common mosquito-transmitted arboviral diseases of tropical and few subtropical areas of the world. It is estimated that 100 million cases occur every year and 2.5 billion people are at risk. Hemorrhagic complications causing encephalopathy is quite a rare presentation but usually fatal. We discuss the peri-operative management of 8 uncommon cases of intracranial hemorrhage (ICH) in dengue. High index of suspicion is required for prompt diagnosis and treatment.Eighteen dengue serology positive patients who presented with neurological manifestations were managed in neurosurgery unit of our tertiary health care center in six months duration. Most of the patients had deranged prothrombin time and thrombocytopenia. They were given platelet concentrates for correction of thrombocytopenia. All vital parameters and neurologic status were closely monitored in high dependency unit. Eight of these patients had deterioration in neurologic status; five of them underwent surgery.All patients who underwent surgery had excellent outcome. Rest of the patients including one patient of cervical extradural hemorrhage were managed conservatively with intravenous fluid and cerebral decongestants. Two patients with deep-seated bleed deteriorated very rapidly and died. Rest who were managed either surgically or conservatively including cervical EDH improved well without any residual deficit.High index of suspicion of ICH is required in dengue especially during convalescence. Special attention should be given to those patients who are disoriented and have altered sensorium and should not be misinterpreted as fever delirium or toxic encephalopathy. It needs immediate attention and investigation. Timely diagnosis and intervention can save lives.Nepal Journal of Neuroscience 13:43-46, 2016