Background and Objectives:Endotracheal intubation is the most important and crucial step during administration of general anesthesia. It is more so in pediatric patients with associated deformities of cleft lip, palate, and alveolus. Propofol, an intravenous (i.v.) induction agent, has profound depressant effect on airway reflexes with a quick and smoother induction. Similarly, sevoflurane, an inhalational agent, has relatively pleasant smell, low airway irritability, and more cardiostable properties. Hence, we sought to compare effectiveness of propofol with sevoflurane in achieving good intubation conditions without the use of muscle relaxants.Materials and Methods:In this prospective randomized study, eighty children belonging to American Society of Anesthesiologist physical status Class I and II, aged 1–10 years, scheduled for cleft surgery were included. All participants were premedicated. Patients were allotted to Group A and Group B randomly. Group A received propofol and Group B received sevoflurane as induction agents. Tracheal intubation was attempted in all patients at 150 s. Intubation conditions were assessed by using Steyn modification of Helbo–Hansen intubating conditions score. Statistical analysis was done using Student's t-test and Chi-square test with P < 0.05 regarded as significant.Results:Group B patients receiving sevoflurane had significantly more clinically acceptable intubation conditions than patients of Group A receiving i.v. propofol (P = 0.001).Conclusion:We conclude that intubation conditions using inhalational 8% sevoflurane are superior to i.v. propofol of 3 mg/kg for tracheal intubation without muscle relaxants in children undergoing cleft surgeries.

Introduction:Colonoscopy is a mildly painful procedure requiring conscious sedation. Though propofol is a widely used anesthetic agent in day-care procedures due to its rapid onset and quick recovery has a drawback of requiring resuscitation maneuvers more often than the conventional methods. Dexmedetomidine, a newly introduced, highly selective α2-adrenergic receptor agonist possessing hypnotic, sedative, anxiolytic, sympatholytic, and analgesic properties with impressive safety margin, needs to be explored for use in conscious sedation for colonoscopy procedure among South Indian population.Materials and Methods:A prospective randomized comparative study was conducted on patients aged between 25 and 60 years with the American Society of Anesthesiologist physical status classes I and II posted for colonoscopy under monitored anesthesia care. Study group was randomly divided into two groups and administered propofol and dexmedetomidine. The primary outcome variable was assessments of sedation scores between the two groups. Secondary outcome variables were pain score assessments, hemodynamic comparisons, and adverse events among the two groups. Appropriate statistical tests were applied to compare the findings.Results:After comparisons between the two groups, we found that patients on dexmedetomidine had similar sedation score as that of patients on propofol. However, there was a significantly higher incidence of systemic hypotension. Requirement of rescue analgesia and adverse events and other hemodynamic fluctuation were similar in both the groups.Conclusion:We conclude that dexmedetomidine has similar efficacy as propofol for conscious sedation required during colonoscopy. Occurrence of systolic hypotension was, however, significantly more among the group receiving dexmedetomidine.

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Background and Aims:Hypotensive anaesthesia reduces intra-articular bleed and promotes visualisation during arthroscopy. The haemodynamic effects of inhalational agents isoflurane and sevoflurane were studied extensively, and both were found to reduce mean arterial pressures (MBP) to an equivalent magnitude. We investigated the relative ability of isoflurane vis-a-vis sevoflurane to maintain the target systolic blood pressure (SBP) in patients undergoing shoulder arthroscopic procedures.Methods:In a prospective randomised study, 59 patients in two groups of 30 and 29 patients each received concomitant general anaesthesia (1.2–1.5 MAC of isoflurane and sevoflurane) and interscalene brachial plexus block. Nitrous oxide was used in both groups. Intraoperatively, serial blood pressure recordings of SBP, diastolic blood pressure (DBP), MBP and heart rates were done at every 3rd min intervals. The manipulations needed to achieve target SBP (T = 90 mmHg) for optimal arthroscopic visualisation and treat unacceptable hypotensive episodes were noted. Conventional statistical tests and process capability index (PCI) evaluation were both deployed for data analysis.Results:Lower mean SBP and DBPs were recorded for isoflurane patients as compared to sevoflurane (P < 0.05, for mean, maximum and minimum recordings). Higher mean heart rates were recorded for isoflurane (P < 0.05). PCIs indicated that isoflurane was superior to sevoflurane in the ease of achieving target SBP of 90 mmHg as well as maintaining blood pressures in the range of 80–100 mmHg.Conclusion:Isoflurane provides better intraoperative haemodynamic status vis-a-vis sevoflurane in patients undergoing shoulder arthroscopic surgery with preliminary interscalene blockade. The PCI can be a useful additional medical data analysis tool.

Background:The sparing of ulnar nerve often leads to the failure of the upper limb blockade. It has been claimed that local anesthetic injection at the site of stimulator evoked finger flexion response is associated with highest success rate of a successful block. The lower trunk stimulation of plexus should yield similar results as this trunk contributes significantly for median and ulnar nerves of hand and forearm.Materials and Methods:The patients with intact anatomical upper limb structures underwent (a) combined ultrasound (USG) assisted nerve stimulator evoked motor response evaluation or in (b) open brachial plexus trunk stimulation evaluations. The individual patient's lower trunk stimulation motor responses were documented.Results:When combined the results of both USG and open plexus groups, wrist flexion was seen in 52%, finger flexion in 61% and forearm pronation or twitches of anterior compartment in 48% of total subjects studied. These responses were noted either separately or in combinations.Conclusion:We conclude other than finger flexion, the wrist flexion the forearm twitches, pronation and wrist adduction may be used for lower trunk blockade and thus for higher accuracy.

Background and Aims: Evaluations of adverse heart rate (HR)-responses and HR-variations during anaesthesia in beach-chair-position (BCP) for shoulder surgeries have not been done earlier. We analysed the incidence, associations, and interpretations of adverse HR-responses in this clinical setting. Methods: We performed a meta-analysis of trials that reported HR-related data in anaesthetised subjects undergoing elective shoulder surgeries in BCP. Studies included prospective, randomised, quasi-randomised and non-randomised, controlled clinical trials as well as observational cohorts. Literature search was conducted in MEDLINE, EMBASE, CINHAL and the Cochrane Central Register of Controlled Trials of the 21 st century. In the first analysis, we studied the incidence and associations of bradycardia/hypotension-bradycardia episodes (HBE) with respect to the type of anaesthesia and different pharmacological agents. In the second, we evaluated anaesthetic influences, associations and inter-relationships between monitored parameters with respect to HR-behaviours. Results: Among the trials designed with bradycardia/HBE as a primary end point, the observed incidence of bradycardia was 9.1% and that of HBE, 14.9% and 22.7% [(for Interscalene block (ISB) ± sedation) subjects and general anaesthesia (GA) + ISB, respectively]. There was evidence of higher observed risk of developing adverse HR-responses for GA subjects over ISB (Risk Difference, P < 0.05). Concomitant use of β-agonists did not increase risk of HBEs ( P = 0.29, I 2 = 11.4%) or with fentanyl ( P = 0.45, I 2 = 0%) for ISB subjects (subgroup analysis). Fentanyl significantly influenced the HR-drop over time [meta-regression, estimates (standard error), 14.9 (5.4), 9.8 (4.3) and 17 (2.6); P = 0.007, 0.024 and <0.001; for early, mid and delayed periods, respectively] in GA subjects. With respect to number of subjects experiencing cerebral desaturation events (CDEs), total intravenous anaesthesia (TIVA)- propofol had higher risk over inhalational anaesthesia ( P = 0.006, I 2 = 86.7%). Meta-correlation analysis showed relationships between the HR and rSO 2 (regional cerebral oxygen saturation) or SjvO 2 (jugular venous oxygen saturation) values (r = 0.608, 95%CI, 0.439 to 0.735, P < 0.001, I 2 = 77.4% and r = 0.397, 95%CI, 0.151 to 0.597, P < 0.001, I 2 = 64.3%, respectively). Conclusions: There is not enough evidence to claim the associations of adverse HR-responses with any specific factor. H...

Background: Prophylaxis for cerebral desaturation events (CDEs) during anesthesia in the beach chair position (BCP) for shoulder surgeries has not been evaluated. We systematically analyzed the effectiveness of various prophylactic measures used in this clinical setting.Methods: We performed a meta-analysis (PROSPERO; no. CRD42020167285) of trials reporting CDEs and regional cerebral oxygen saturation (rSO2) and jugular venous oxygen saturation (SjvO2) values in anesthetized patients undergoing shoulder surgery in BCP. Considering the type of prophylactic measures used (pharmacological or non-pharmacological), a subgroup analysis was planned. Outcomes included (1) rSO2 and SjvO2 data with and without prophylactic measures for CDEs, recorded for different time intervals, and (2) the number of patients experiencing CDEs and hypotension. Results: Twelve studies (786 patients) were included in the analysis. We observed lower absolute rSO2 values for early and all-time periods for vasoactive agent prophylaxis. The lowest achieved rSO2 values were also lower for vasoactive agent prophylaxis. Risk of CDEs was higher with vasoactive agent prophylaxis. Subgroup analysis identified targeted mild hypercarbia as effective in preserving cerebral oxygenation. Similarly, targeted mild hypercarbia prevented the fall in rSO2 with position change. Meta-regressions revealed statistically significant highest estimates for vasoactive agent prophylaxis in contrast to targeted mild hypercarbia. Likelihood of not developing CDEs was higher for targeted mild hypercarbia. In contrast to rSO2, most prophylactic methods reduced hypotensive episodes. Conclusions: Targeted mild hypercarbia can reduce BCP-related CDEs. Evidence does not favor prophylactic use of vasoactive agents for the prevention of cerebral desaturations irrespective of whether their use interferes with cerebral oximetry readings.