Anaesthesia

Continuous wound infiltration of local anaesthetics for acute postoperative pain – A revisit Vimi Rewari, Rashmi Ramachandran Indian Journal of Anaesthesia 2019 63(6):425-427

Focused review on management of the difficult paediatric airway Andrea S Huang, John Hajduk, Catherine Rim, Sarah Coffield, Narasimhan Jagannathan Indian Journal of Anaesthesia 2019 63(6):428-436 Management of the difficult paediatric airway management may be associated with a high rate of complications. It is important that clinicians understand the patient profiles associated with difficult airway management, and the equipment and techniques available to effectively manage these children. The goal of this focused review is to highlight key airway management concepts when managing the paediatric difficult airway. This includes understanding the advantages and limitations of various airway equipment designed for children and reviewing the difficult airway algorithm with its unique considerations for the paediatric patient. Early recognition of known risk factors and thorough preparation may be helpful in reducing the risk of complications during difficult airway management in children.

Continuous wound infiltration of bupivacaine at two different anatomical planes for caesarean analgesia – A randomised clinical trial Diana Thomas, Sakthirajan Panneerselvam, Pankaj Kundra, Priya Rudingwa, Ranjith K Sivakumar, Gowri Dorairajan Indian Journal of Anaesthesia 2019 63(6):437-443 Background and Aims: Continuous wound infiltration of local anaesthetics provide postoperative analgesia by peripheral nociceptors blockade. The placement of wound infiltration catheter in the optimal anatomical plane of surgical wound may play a significant role in reducing postoperative pain depends on the surgical procedure. We hypothesised that preperitoneal infusion of local anaesthetics will reduce the postoperative opioid consumption as compared to subcutaneous infusion following cesarean section. Methods: This was a randomised, double-blinded clinical trial. Fifty-two pregnant women who underwent lower segment caesarean section by Pfannensteil incision, under spinal anaesthesia, were randomised to group 'subcutaneous' and group 'preperitoneal'. A wound infiltration catheter was placed in the subcutaneous or preperitoneal plane, depending on their randomisation at the end of the surgery. Bupivacaine of 0.25% at 5 mL/h was infused for the next 48 h. Pain was assessed using numerical rating scale at 1, 2, 3, 4, 5, 6, 12, 24, 36 and 48 h after surgery. Cumulative postoperative consumption and adverse effects of morphine and complications of the procedure were looked for. Results: Cumulative 48-h morphine consumption showed no statistical significance between the preperitoneal group (15.96 ± 7.69 mg) and subcutaneous group (21.26 ± 11.03 mg); P = 0.058. Pain score was comparable. Independent T-test and Mann–Whitney test were the statistical tests used for continuous and categorical data, respectively. Conclusion: Postoperative cumulative morphine consumption and pain scores are comparable when bupivacaine is infused continuously through wound infiltration catheter either in the preperitoneal or subcutaneous layer following Caesarean delivery.

Derivation and validation of a formula for paediatric tracheal tube size using bootstrap resampling procedure M Ganesh Kumar, Meenakshi Atteri, Yatindra K Batra, Lakshminarayana Yaddanapudi, Sandhya Yaddanapudi Indian Journal of Anaesthesia 2019 63(6):444-449 Background and Aims: The accuracy of age-, length- and weight-based formulae to predict optimal size of uncuffed tracheal tubes (TTs) in children varies widely. We determined the accuracy of age, length and weight in predicting the size of TT in Indian children, and derived and validated a formula using the best predictor. Methods: In the derivation phase, 100 children aged 1-8 years undergoing general anaesthesia and tracheal intubation with an uncuffed tube were prospectively studied. The correct size of the TT used was confirmed using the leak test. A bootstrap resampling procedure was used to estimate the accuracy of the predictors (age, weight, or length alone; length and age; length and weight; and length, weight and age). The best predictor was used to derive a formula (Paediatric Tube Size Predictor, PTSP) to calculate the size of TT. The accuracy of PTSP was tested in 150 children of the same age group in the validation phase. Results: Length (L (in meters), R2 = 0.61) was the best single predictor of the size of TT and was used to derive the PTSP as internal diameter = 3L + 2.5. In the validation phase, the PTSP predicted the size of TT correctly in 75% of children. Re-intubation was associated with a higher incidence of respiratory morbidity than one-time tracheal intubation. Conclusion: Length of the child predicts the size of an uncuffed TT better than age and weight. The PTSP formula based on length correctly predicts the size of uncuffed TT in 75% of children.

Comparative efficacy of postoperative analgesia between ultrasound-guided dual transversus abdominis plane and Ilioinguinal/Iliohypogastric nerve blocks for open inguinal hernia repair: An open label prospective randomised comparative clinical trial Vinod Hosalli, Basavaraja Ayyanagouda, Preetika Hiremath, Uday Ambi, SY Hulkund Indian Journal of Anaesthesia 2019 63(6):450-455 Background and Aims: Transversus abdominis plane (TAP) and Ilioinguinal/Iliohypogastric (IL/IH) nerve blocks have been advocated in reducing postoperative pain and additional analgesic requirement following lower abdominal surgeries with varied effect. The aim of this study was to determine post-operative analgesic efficacy by comparing dual TAP [combining TAP and IL/IH nerve blocks] and IL/IH nerve block alone for open inguinal hernia repair. Methods: Two hundred patients undergoing elective primary unilateral open inguinal hernia repair with a mesh were included in to this trial. Ultrasound-guided dual TAP (D-TAP Group) or IL/IH (IL/IH Group) nerve block were administered to patients following subarachnoid block according to their group allocation, with 0.5% ropivacaine. Post operatively patients were monitored for visual analogue scale (VAS) scores at rest (at 4, 12, 24 and 48h) and during movement (at 24, 48 h, 3 and 6 months). Pain scores at 3 and 6 months were assessed by telephonic interview, using the DN4 questionnaire for neuropathic pain. The statistics was obtained using Chi-square test for proportions in qualitative data and student's unpaired t test for quantitative data. P value <0.05 was considered significant. Results: The pain scores at rest (VAS-R) were significantly lower at 12 hours and 24 hours (P < 0.001) in D-TAP group, while pain scores at movement were significantly lower (P < 0.001) in D-TAP group at 24 and 48 hours compared to IL/IH group. The mean time required for first rescue analgesic was longer in D-TAP group (5.590 ± 2.386 hr) in comparison to IL/IH group (3.1053 ± 1.1822h). Conclusion: Ultrasound-guided dual TAP block provides more effective post-operative analgesia in open inguinal hernia repair.

McGrath MAC video laryngoscope versus direct laryngoscopy for the placement of double-lumen tubes: A randomised control trial Sumitra G Bakshi, Ajay Gawri, Jigeeshu V Divatia Indian Journal of Anaesthesia 2019 63(6):456-461 Background and Aims: Role of video laryngoscopes (VLs) in the management of difficult airway with single-lumen tubes (SLTs) is established. VLs provide improved glottis view but are associated with longer time to intubate (TTI). We aimed to compare the TTI for double-lumen tube (DLT) insertion using the McGrath® MAC VL versus direct Macintosh laryngoscope (DL). Methods: Eleven senior anaesthesiologists experienced in SLT insertion, but not DLT insertion with VL participated. Seventy-four adults belonging to American Society of Anesthesiologists physical status I–II posted for elective surgery needing lung isolation were randomised to both intubator and laryngoscope (VL/DL). Primary endpoint was TTI; secondary endpoints included glottic view assessed by the Cormack and Lehane (CL) grade, need for external laryngeal manipulation, ease of intubation [scored using Numeric Rating Scale (1 – easiest, 10 – most difficult)] and associated complications. TTI was compared using Student's t-test. Results: No difference was found in TTI with DL and VL [(56.6 ± 14) s vs (64.4 ± 24) s, P = 0.104] as well as ease of use of laryngoscope [median score of 2 (1–3) in both]. Use of VL resulted in more patients with CL I glottic view – 86.0% versus 58.0% (P = 0.007). Fewer patients required external laryngeal manipulations (19% vs 47%, P = 0.013), and complications were fewer in the VL group (5% vs 24%, P = 0.023). Conclusion: TTI for DLT insertion was similar with VL and DL. However, VL was associated with better glottis visualisation, reduced need of external laryngeal manipulation and fewer complications.

Comparison of analgesic efficacy of continuous bilateral transversus abdominis plane catheter infusion with that of lumbar epidural for postoperative analgesia in patients undergoing lower abdominal surgeries Sabina Regmi, S Srinivasan, Ashok S Badhe, M V S Satyaprakash, S Adinarayanan, VK Mohan Indian Journal of Anaesthesia 2019 63(6):462-468 Background and Aims: Epidural analgesia (EA) and transversus abdominal plane (TAP) block have been part of multimodal analgesia techniques for postoperative pain relief in abdominal surgeries though EA has been established as gold standard. This study assesses and compares the analgesic efficacy of continuous bilateral TAP catheter infusion and lumbar epidural infusion. Methods: In this randomised, single-blind, prospective, non-inferiority trial, 75 patients were randomised to receive a bolus dose of 15 ml, 0.25% bupivacaine followed by an infusion of 5–12 ml/h of 0.125% bupivacaine via lumbar epidural in EA group and a bolus dose of 0.4 ml/kg of 0.25% bupivacaine bilaterally via TAP catheter followed by continuous infusion at 5ml/h of 0.125% bupivacaine in TAP group postoperatively. VAS scores (primary objective) and sensory dermatome blockade were recorded at 1, 4, 8, 12 and 24 h. Total morphine consumption, PONV, incidence of hypotension and patient satisfaction scales were recorded at the end of 24 hours. Results: The median VAS scores were comparable between the groups at 1, 4, 8, 12 and 24 hours both at rest (P = 0.11, 0.649, 0.615, 0.280 and 0.191, respectively) and on coughing (p = 0.171, 0.224, 0.207, 0.142 and 0.158, respectively). Total morphine consumption in 24 h between TAP and EA group was comparable (p = 0.366). There was no statistical difference in the incidence of hypotension, PONV and patient satisfaction scale. Conclusion: Continuous bilateral TAP block is as efficacious as the continuous lumbar epidural infusion in relieving postoperative pain in patients undergoing lower abdominal surgeries.

Effect of dexamethasone as an adjuvant to ropivacaine on duration and quality of analgesia in ultrasound-guided transversus abdominis plane block in patients undergoing lower segment cesarean section - A prospective, randomised, single-blinded study Anie Gupta, Alok Gupta, Neeraj Yadav Indian Journal of Anaesthesia 2019 63(6):469-474 Background and Aims: Ultrasound guided transversus abdominis plane block is an efficacious abdominal field block. The aim was to determine the effect of dexamethasone to 0.375% ropivacaine on the analgesic duration of TAP block in patients undergoing lower segment cesarean section (LSCS). Methods: A single-blinded randomised control study was conducted on 90 patients, who were divided in two groups of 45 each. Group R received 0.375% ropivacaine (25 ml) with normal saline (1 ml) each side and group D received 0.375% ropivacaine (25 ml) with dexamethasone 4 mg (1 ml) each side in transversus abdominis plane block after lower segment cesarean section. Primary objective was to compare time to first rescue analgesia and secondary objectives to compare the total amount of analgesia required in first 24 h postoperatively, visual analog scale scores for somatic and visceral pain and incidence of nausea and vomiting, between the two groups. Student's t test, Chi-square, or Fisher's exact test were performed using SPSS 17.0. Results: Time to first rescue analgesia was significantly less in group R (11.62 ± 3.80 h) compared to group D (19.04 ± 4.13 h) (P < 0.001). Total tramadol consumed in 24 h was significantly higher in group R (86.67 ± 30.55 mg) than group D (35.56 ± 39.54 mg) (P < 0.001). Visual analog scale scores for both somatic and visceral pain were significantly higher in group R than group D at 8 h, 12 h, and 24 h postoperatively. Conclusion: Addition of dexamethasone to ropivacaine in transversus abdominis plane block significantly prolongs the duration of postoperative analgesia.

Influence of time interval between coronary angiography to off-pump coronary artery bypass surgery on incidence of cardiac surgery associated acute kidney injury Deepak Prakash Borde, Balaji Asegaonkar, Pramod Apsingekar, Sujeet Khade, Bapu Khodve, Shreedhar Joshi, Antony George, Amey Pujari, Anand Deodhar Indian Journal of Anaesthesia 2019 63(6):475-484 Background and Aims: Cardiac surgery associated acute kidney injury (CSA-AKI) is serious complication after cardiac surgery. The time interval between coronary angiography (CAG) to coronary artery bypass surgery (CABG) is proposed as modifiable risk factor for reduction of CSA-AKI. The aim of this study was to assess influence of time interval between CAG to off-pump CABG (OPCABG) on incidence of CSA-AKI. Methods: This was a retrospective observational study of 900 consecutive OPCABG patients who were classified into 2 groups based on time interval between CAG and OPCABG: ≤7 days or longer. Results: The incidence of CSA-AKI was 24% (214/900) by Kidney Disease: Improving Global Outcomes (KDIGO) definition. The incidence of CSA-AKI was not significantly different in two groups (22% in >7 days groupvs. 28% in ≤7 days group, P = 0.31). The factors independently associated with CSA-AKI were: Age (OR 1.04; P = 0.002), baseline creatinine (OR 1.99,; P = 0.03), moderate LV dysfunction (OR 1.64,; P = 0.007) and blood transfusion (OR 3.3,; P < 0.001), but not the time interval between CAG and OPCABG. The incidence of CSA-AKI was highest in patients with creatinine clearance (CC) <50 mL/min when OPCABG was performed ≤7 days of CAG (16/38; 42%, OR 2.7, 1.4-5.4; P = 0.005) compared to lowest incidence of CSA-AKI in patients with CC >50 mL/min and OPCABG performed >7 days of CAG (114/543; 21%). Conclusion: This study demonstrated that there is no increased incidence of CSA-AKI if OPCABG is performed ≤7 days of CAG; but we recommend to postpone OPCABG for seven days if CC is <50 mL/min and there is no urgent indication for OPCABG in order to reduce incidence of CSA-AKI.

Effect of entropy-guided low-flow desflurane anaesthesia on laryngeal mask airway removal time in children undergoing elective ophthalmic surgery – A prospective, randomised, comparative study Shivangi Mishra, Renu Sinha, Bikash Ranjan Ray, Ravinder Kumar Pandey, Vanlal Darlong, Jyotsna Punj Indian Journal of Anaesthesia 2019 63(6):485-490 Background and Aims: In children, entropy-guided titration of isoflurane and sevoflurane leads to faster recovery after anaesthesia. However, role of entropy in recovery following desflurane anaesthesia is not known. Hence, we compared laryngeal mask airway (LMA) removal time and desflurane consumption with entropy and minimal alveolar concentration–guided titration in children given low-flow desflurane anaesthesia. Methods: After ethics committee approval and parental consent, 80 American Society of Anesthesiologists grade I–II children, age 2–14 years, undergoing elective ophthalmic surgery were randomised into entropy and minimal alveolar concentration–guided groups. After LMA insertion, anaesthesia was maintained using oxygen, air (FiO2 0.5) and desflurane using low fresh gas flow of 0.75 L/min. In the entropy-guided group, desflurane was titrated to maintain state entropy between 40 and 60. In the minimal alveolar concentration–guided group, desflurane was titrated to maintain a minimal alveolar concentration between 1 and 1.3. We recorded LMA removal time (from switching off desflurane at the end of surgery till removal of LMA), haemodynamic parameters, uptake and consumption of desflurane between the groups. Results: LMA removal time was significantly decreased in the entropy-guided group in comparison to the minimal alveolar concentration–guided group (4.34 ± 2.03 vs 8.8 ± 2.33 min) (P < 0.0001). Consumption of desflurane was significantly less in the entropy-guided group compared with the minimal alveolar concentration–guided group (18.7 ± 5.07 vs 25.3 ± 8.11 mL) (P < 0.0001). Conclusion: Entropy-guided low-flow desflurane anaesthesia is associated with faster LMA removal and reduced consumption of desflurane in children undergoing ophthalmic surgery.

Alexandros Sfakianakis
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