Background: Correct placement of nasogastric tube (NGT) placement often becomes difficult in anesthetized, intubated adult patients due to lack of cooperation from patient and the propensity of the tube to travel the same course of path. Preexisting throat pack is supposed to resist the normal passage of the NGT as per common belief. Only one study has evaluated this in pediatric population and the result is encouraging. Aims and Objectives: Hence, the present study has been carried out in adult population to compare the success rate of correct placement of NGT in anesthetized intubated adult patients with the pharyngeal (throat) pack in its position in comparison with no throat pack. This is to examine the effect of preexisting throat pack whether it assists or resists the normal passage of the NGT. Materials and Methods: One hundred and eighty patients were recruited for this interventional and single-blind study. After induction of anesthesia and intubation, the patients were randomized to receive NGT insertion following either blind insertion of the NGT without a pharyngeal pack (group A, n=90) or receive the NGT placement in the same technique but after placement of a pharyngeal pack. The success rate of correct placement of NGT in the first attempt (primary outcome), the procedure time, and adverse events was recorded. Results: Successful insertion of NGT in first attempt was considerably higher in throat pack in situ group compared to blind insertion without a throat pack 81 (90%) versus 63 (70%), respectively (P=0.001). The procedure time for successful placement of NGT was found comparable between the two groups. Significant decrease in coiling is seen in “throat pack in situ” group compared with blind insertion technique (P=0.003). Conclusion: In view of considerable higher success rate and reduced adverse events, it can be concluded that the pre-existing appropriately placed throat pack can facilitate the placement of NGT instead of putting any hindrance.
Background: Early prediction of severity of acute pancreatitis (AP) is important for management of AP patients with escalation of care and aggressive therapy which can reduce complications. Bedside index of severity in AP (BISAP) score is helpful in early diagnosis of severe AP. D-dimer, a biomarker of secondary fibrinolysis may be helpful in predicting the severity of pancreatitis. Aims and Objectives: The objective of this study was to evaluate the two scoring systems - the BISAP score and D-dimer in early prediction (within 24 h) on the severity of AP and to analyze how D-dimer correlates with BISAP score. Materials and Methods: Seventy-five patients, aged 18–70 years, suffering from AP due to any cause were included for this prospective, observational study. Within 24 h of admission D-dimer was estimated and BISAP score was calculated. The severity was assessed based on D-dimer level and BISAP scoring systems within 24 h of hospital admission and data were tabulated for analysis. The D-dimer level >2.5 mg/L was considered to be suggestive of severe pancreatitis. The BISAP score >2 in first 24 h was defined as predictive of severe pancreatitis. Spearman rank correlation was used for an analysis of the association between two set of data (BISAP scores and d-dimer levels) and thus to measure the strength and direction of the relationship between the two variables. Results: In the present study, 37.3% of the patients had D-dimer ≤2.5 mg/L and 62.7% had D-dimer>2.5 mg/L’ on calculating the Pearson’s correlation on the ranked values of the data (BISAP scores and D-dimer levels), the correlation coefficient (Spearman’s Rho, designated as “rs”) was found to be 0.406 which indicates about moderate positive correlation. Conclusion: D-dimer testing can be used as an alternative test to predict the severity of AP. It shows a moderate correlation with BISAP scoring.
Background: Although various adjuvants have been added to local anesthetic agents to potentiate its effect, dexmedetomidine is a relatively new drug with only a fewer studies. Aims and Objectives: The present study has been conducted to compare the efficacy of intrathecal hyperbaric bupivacaine alone with dexmedetomidine of two different doses as adjuvants in spinal anesthesia for the lower abdominal surgery. Materials and Methods: This was a double-blinded, randomized, and controlled trial. Total 120 patients of American Society of Anesthesiologists physical status I and II, 70 male and 50 female, aged between 20 and 60 years, were randomized into three groups receiving 15 mg 0.5% hyperbaric bupivacaine with normal saline, 4 μg (microgram) dexmedetomidine, and 2 μg dexmedetomidine, respectively, administered intrathecally. Results: There was significant difference among all three groups with regard to the onset of sensory block and time to reach the highest level of sensory block. Time to reach T10 dermatome, time to reach Bromage 3 motor block, the mean regression time to S1 dermatome level, the mean regression time to reach Bromage 0, and time to first requirement of rescue analgesia – all these variables showed significance when 4 μg dexmedetomidine additive group was compared with 2 μg dexmedetomidine additive group and bupivacaine alone group. Conclusion: In our double-blinded, randomized, and controlled trial, 4 μg intrathecal dexmedetomidine coadministered with 0.5% hyperbaric bupivacaine showed superior efficacy. Further, larger trials are needed to confirm our findings.
Background: Direct laryngoscopy and endotracheal intubation elicit hemodynamic pressor responses which may be hazardous in high risk patients. Fentanyl, a low cost synthetic opioid, when used judiciously, may be a good option to attenuate this stress response. Aims and Objectives: The present study has been conducted to compare the efficacy of three different doses of intravenous fentanyl in attenuation of hemodynamic pressor response to laryngoscopy and endotracheal intubation in elective surgery under general anesthesia. Materials and Methods: It was a double-blinded randomized controlled trial. A total of 90 patients of American Society of Anesthesiologists physical status I and II, 55 male and 35 female, aged between 20 and 55 years, were randomized into three groups receiving 2, 3, and 4 μg/kg of injection fentanyl, respectively, administered intravenously 5 min before direct laryngoscopy and endotracheal intubation. Results: There were significant differences in hemodynamic variables among all three groups at 1, 3, 5, and 10 min after endotracheal intubation. Just after endotracheal intubation; heart rate, mean arterial pressure, and diastolic arterial pressure – all these variables showed significance between 3 μg/kg and 4 μg/kg groups only. Incidence of nausea/vomiting showed statistical significance between 2 μg/kg and 4 μg/kg groups only. Conclusion: In our double-blinded randomized controlled trial, 4 μg/kg of injection fentanyl administered 5 min before laryngoscopy and intubation, has showed superior efficacy in suppressing hemodynamic stress responses associated with it. Further, larger trials are needed to confirm our findings.
Background: Various adjuvants are added to local anesthetics to increase the duration of block during supraclavicular brachial plexus (SCBP) block. Dexmedetomidine, a newer and potent alpha2 receptor agonist, has 10 times higher selectivity than clonidine. Many studies have already evaluated the efficacy of clonidine and dexmedetomidine as perineural adjuvants and have reported wide variations in the prolongation of post-operative analgesia. Some studies have reported the absence of adjuvant’s effect while a few have not focused all the facets of block characteristics. Aims and Objectives: The aim of the study was to compare the efficacy of clonidine and dexmedetomidine as adjuvant to ropivacaine during SCBP block for the upper limb surgeries, in terms of duration of post-operative analgesia (Primary outcome). The onset and duration of sensory and motor block, and adverse effects, if any, were observed. Materials and Methods: Ninety patients, aged between 40 and 60 years of either sex, undergoing upper limb surgery, were randomly allocated in to three groups to receive either 30 ml of 0.5% ropivacaine and 2 ml saline (Group R, n=30) or 30 ml 0.5% ropivacaine plus clonidine (1 mcg/kg) plus saline to make a total volume 32 ml (Group C, n=30), or 30 ml 0.5% ropivacaine and dexmedetomidine (1 mcg/kg) plus saline to make a total volume 32 ml (Group D, n=30). The duration of post-operative analgesia, other block characteristics, and adverse events, if any, was assessed. Results: Mean duration of post-operative analgesia was found to be considerably higher in dexmedetomidine group compared with clonidine group and ropivacaine alone group (664.13 vs. 551.77 vs. 465.47, respectively, P<0.001). The duration of sensory and motor block was considerably longer in dexmedetomidine group compared with clonidine and control group. Adverse events were comparable among the three groups. Conclusion: Dexmedetomidine appears to be a better alternative to clonidine as adjuvant in terms of prolonged post-operative analgesia and comparable adverse events.
Background: Nasogastric tube (NGT) insertion is an essential procedure in the operating room for which the anesthesiologists often take the responsibility. This simple procedure often becomes difficult in anesthetized patients. Literature reveals the flooding of studies and novel techniques are in the pipeline, indicating that quest for the best is still on. Aims and Objectives: The aim of the study was to determine the proportion of patients in whom successful NGT insertion would be possible in the first attempt using either the “Reverse Sellick’s maneuver (RSM) with throat pack in situ” technique or RSM alone; and to compare the proportions between the two groups. Materials and Methods: This interventional study was performed on 222 adult patients (≥18 years), undergoing abdominal surgeries requiring intraoperative NGT insertion. Patients received NGT insertion using the combined RSM with “throat pack in situ” technique (Group A, n=111) or RSM alone (Group B, n=111). The proportion of patients in whom successful NGT insertion was possible in the first attempt using either of the techniques and the time taken for correct placement of NGT in both the groups. In addition, the incidence of adverse events was noted. Results: Although, NGT placement was possible in higher proportions of patients in Group A in first attempt compared with Group B (91% vs. 83.8%), it was not significant on analysis (P=0.106). The procedure time in both the groups was comparable (30.0±4.0 vs. 29.9±4.3, P=0.859). Coiling was found to be significantly more in the RSM alone technique as compared to the combined method. (P=0.04). Conclusion: With comparable success rate and lesser incidence of adverse events, it can be commented that the RSM with throat pack in situ technique appears to be a better alternative to RSM alone.
Background: The tenet of any surgery is to reduce the morbidity and mortality. The outcome is not solely dependent on surgeon’s operative expertise alone, but also significantly influencedby a lot of patient factors. The Physiological and Operative Severity Score for the enUmeration of Morbidity and Mortality (POSSUM), a risk-adjusted scoring system, has already been used in various parts of India. There is scarcity of published research using this tool in the population of Eastern India. Aims and Objectives: The aim of the study was to determine the efficacy of modified version Portsmouth-POSSUM (P-POSSUM) scoring system in predicting the postoperative morbidity and mortality in population of East India. Materials and Methods: The study was carried out in 50 patients of either gender, of age group 13–80 years, undergoing emergency laparotomy and followed up to 30-day post-operative follow-up of all patients till the sample size of 50 was reached. The physiological scores were recorded during admission and the operative severity score was recorded according to the intra-operative findings of operating surgeon. Any post-operative morbidity or death was recorded during hospital stay or on follow-up for a period of 30 days. The Hosmer–Lemeshow test was used for goodness-of-fit in logistics regression for mortality risk prediction model. The ratio of observed and expected rates (O: E ratio) was calculated. Results: Using the scoring tool, no significant difference was observed between the expected and observed mortality (Chi-square 2.166; df=8; P=0.976, O: E ratio 1.4) but a considerable difference was observed between the observed between the expected morbidity rates (χ²=22.806, df=8, P=0.004, O: E ratio 1.137). Conclusion: The P-POSSUM score was able to accurately predict the mortality in Eastern India surgical settings. However, the model was not that accurate in prediction of morbidity.
Background: Demography and clinical presentation of diabetic foot ulcer varies across geographical location. Multiple imaging modalities such as plain radiography and magnetic resonance imaging (MRI) are used to evaluate osteomyelitis or neuroarthropathy in diabetic foot. Plain radiography is a low cost and easily available test while MRI is reported to be of higher sensitivity and specificity for delineating the extent of soft tissue and bone involvement. Aims and Objectives: The study was designed to determine the spectrum of demographic and clinical findings and to find the utility of different diagnostic modalities such as clinical, plain radiography, and MRI that were used to differentiate between osteomyelitis and neuroarthropathy. Materials and Methods: After obtaining permission of Institute’s Ethics Committee’s permission, this observational study was carried out among patients, males and females aged 13 years and above, who presented with diabetic foot ulcer for treatment. The study spanned from March 2020 to August 2021 to reach a sample of 50 patients following non-random purposive sampling. A pro forma (containing history, physical examination findings, and laboratory investigations) was used to explore patient data. Besides clinical diagnosis, plain radiography and MRI were used to evaluate the clinical findings. Results: In the study, most of the subjects were between 51 and 70 years of age having diabetes for a duration of 5–15 years. The basis of complications observed is infections, ischemia, and neuroarthropathy. Among the diagnostic modalities used to reach a diagnosis of osteomyelitis or neuroarthropathy, MRI was able to pick up the diagnosis in a greater number of patients for above two entities. Osteomyelitis was identified in 24 (48%) patients and neuroarthropathy was identified in 22 (44%) patients. Use of plain radiography helped in reaching diagnosis in 30% of patients for each category. Clinical diagnosis about osteomyelitis or neuroarthropathy was made in 22% and 26% of patients, respectively. However, on analysis, it was not significant. Conclusion: The present study showed a male preponderance. Moreover, MRI was able to categorically diagnose different pathological parameters of osteomyelitis and neuroarthropathy. Marrow edema was detected in a larger proportion of patients among the MRI-diagnosed cases of osteomyelitis and neuroarthropathy. MRI appears to be more useful than plain radiography for clinical diagnosis.
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