Esophageal guidewire-assisted insertion with manual forward laryngeal displacement technique most frequently resulted in correct positioning of the NGT in anesthetized and tracheally intubated patients after the first attempt. This technique is also associated with a lower incidence of procedure-related injuries and is less time-consuming than conventional insertion techniques.
Context:The study was undertaken to observe the effect of different maintenance-fluid regimen on intraoperative blood glucose levels in non-diabetic patients undergoing elective major non-cardiac surgery under general anesthesia.Aims:To know the intraoperative blood glucose levels.Settings and Design:Prospective randomized parallel group study.Subjects and Methods:Two hundred non-diabetic patients (100 in each group) aged between 18 years and 60 years were enrolled for this prospective randomized parallel group study. Group A patients received Ringer's lactate solution and Group B patients received 0.45% sodium chloride with 5% dextrose and 20 mmol/L potassium chloride as maintenance fluid. Capillary blood glucose (CBG) level was measured immediately before initiation of intravenous fluid therapy and thereafter hourly till the end of surgery. If at any time intraoperative CBG was found to be more than or equal to 150 mg/dL calculated dose of human soluble insulin was given as intravenous bolus equal to the amount of CBG/100 units.Statistical Analysis Used:For comparison of normally distributed variables independent sample t test was done. For rest of the data, i.e., CBG_0, CBG_4 and insulin consumption Mann-Whitney U test was employed.Results:63% patients in group B developed at least one episode of hyperglycemia CBG ≥ 150 mg/dL) but only 29% in the Group A did so. Insulin consumption was significantly higher in Group B than in Group A to maintain normoglycemia. The relative risk of becoming hyperglycemic in Group B patients is 2.172 (95% CI 1.544 to 3.057). Number needed to harm, i.e., hyperglycemia, in Group B is 2.941 (95% CI 2 to 5).Conclusions:We conclude that stress induced-hyperglycemic response in patients undergoing major non-cardiac surgery is common in non-diabetic population. Maintenance-fluid therapy by dextrose containing solution as opposed to Ringer's lactate solution increases the incidence of hyperglycemia. To achieve normoglycemia by intravenous bolus dose of human regular insulin, significantly higher doses are required in patients receiving dextrose containing saline as maintenance fluid.
D ifficult and failed tracheal intubations are one of the principal causes of anesthetic-related mortality and morbidity. Difficult intubations are common in obese patients because the limited oropharyngeal space may impede adequate visualization. With the increase in numbers of obese and morbidly obese patients, the incidence of difficult intubations is also likely to rise. The Pentax AWS (Ambu A/S, Ballerup, Denmark) is a video laryngoscope designed to facilitate intubation by providing a video image of the glottis. It has a miniature video camera and a battery-powered, built-in liquid crystal display monitor, which allows a simultaneous view of the glottis with insertion of the endotracheal tube. Reports suggest that this device can help with intubation, but randomized data are lacking. This study compared intubation in obese patients using the Pentax AWS or the standard Macintosh laryngoscope with a no. 4 blade.Patients (n = 105) with a body mass index between 30 and 50 kg/m 2 were randomly allocated to intubation using either a conventional Macintosh laryngoscope no. 4 blade (Macintosh group) or the Pentax AWS (Pentax group). For the Pentax group, the device was placed into the patient's mouth and advanced into the posterior pharynx in the midline until the cross-hair target symbol was centered on the glottic aperture. The endotracheal tube was then advanced toward the trachea. The glottic view for each laryngoscopy was graded using the Cormack-Lehane grading system, and the ease of intubation was graded on a Likert scale (0 = extremely easy to 100 = extremely difficult). The presence of any blood staining and the severity of postoperative sore throat were assessed. Intubation success rate, time and ease of intubation, and occurrence of complications were recorded.Data from 99 patients were analyzed. Median time to intubation was 38 seconds with the Pentax AWS and 26 seconds with the Macintosh. Intubations using the Pentax device were also slower than the Macintosh laryngoscope after adjusting for American Society of Anesthesiologists physical status and Mallampati score. The 2 groups did not differ in the number of attempts, successful intubation on the first attempt (Pentax 86% vs Macintosh 92%); these rates increased to 90% and 100%, respectively, on a second attempt. For patients who needed a third attempt, the intubation was considered unsuccessful. The difficulty of tracheal intubation was worse in the Pentax group compared with the Macintosh group. When the Cormack-Lehane scores of 1 and 2 were considered good and those of 3 and 4 were considered not good, the groups did not differ. The view was good in 86% of patients in the Pentax group. The groups did not differ in bleeding nor in severity of sore throat. These results suggest that the Pentax AWS should not be routinely substituted for the conventional Macintosh no. 4 blade in morbidly obese patients.
BACKGROUNDFailure of adequate postoperative analgesia, defined as Numerical Rating Scale (NRS) pain score > 3 after major abdominal surgery have been reported to be 30% to 50% in a large number of studies. Effective yet inexpensive technique of anaesthesia and postoperative analgesia for major abdominal surgery seemed to be a hitherto elusive entity. MATERIALS AND METHODSIn this randomised, double-blinded study involving ninety-two participants, we investigated the clinical efficacy and safety of morphine plus bupivacaine administered intrathecally versus systemic morphine for pain control in the first 24h postoperative period after major abdominal surgery under relaxant general anaesthesia in a resource-poor setting. RESULTSOur experimental protocol had significant ARR of 0.3043 (95% CI: 0.1554 to 0.4497) at 12h and ARR of 0.3261 (95% CI: 0.1579 to 0.4764) at 24h in the failure of adequate postoperative analgesia (NRS pain score > 3) with an NNT of 3. There were no significant differences in intraoperative vasopressor consumption, the postoperative OASS scores, first 24h urine output, incidence of postoperative nausea and vomiting and Michigan Awareness Classification Instrument Class. The experimental group experienced higher incidence of mild pruritus. The incidence of serious adverse events was nil. CONCLUSIONIn patients undergoing major abdominal surgery under relaxant general anaesthesia in a simulated resource poor setting, intrathecal analgesia with bupivacaine plus morphine is safe and reduces the incidence of failure of adequate analgesia in the first 24h postoperative period. KEYWORDSIntrathecal Analgesia, Major Abdominal Surgery, Resource Poor Setting. HOW TO CITE THIS ARTICLE:Ray S, Kirtania J. Randomised double-blind study of intrathecal bupivacaine-morphine versus systemic morphine analgesia for major abdominal surgery in a resource poor setting.
Modifiable and nonmodifiable factors affecting the inpatient waiting time of surgical patients were identified. Control measures that can reduce the waiting time of inpatients before elective surgery were identified.
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