Archives of Anesthesiology and Critical Care
Volume:10 Issue: 1, Winter 2024

FESS has its share of complications which can be a challenge for both the surgeon as well the anesthetist and achieving a bloodless surgical field is essential So the principle of controlled hypotension can be used to combat this issue.

A hospital-based randomized comparative interventional study was conducted on 60 patients to compare Clonidine (2mcg/kg in 10 ml of saline over 10 minutes before induction followed by an infusion of 1mcg/kg/hr during maintenance) and Esmolol (1mg/kg in 10 ml of saline over 10 minutes before induction followed by an infusion of 1mg/kg/hr during maintenance) to assess and compare the hypotensive properties of both the drugs.

After the induction of anesthesia, there was a significant difference in the mean heart rate, and mean arterial pressure between the two groups throughout the intraoperative period (p-value < 0.05). Both groups achieved a target mean arterial pressure (MAP) of 65-70 mmHg and improved surgical field quality.

This study concluded that clonidine and esmolol both provide hemodynamic stability and a better surgical field in functional endoscopic sinus surgery (FESS). Clonidine also helps in achieving postoperative sedation and analgesia.

Disorders of consciousness, including the vegetative state (VS) and the minimally conscious state (MCS) following brain damage and various complications for the patient, also have economic and social consequences. However, there is still no definitive or effective treatment for this condition. However, there is still no definitive or effective treatment for this condition. Therefore, this study aims to investigate the effectiveness of zolpidem in improving consciousness in patients with acute brain injury.

The present quasi-experimental study was performed from 2020 to 2021 after obtaining the necessary permissions from Zahedan University of Medical Sciences, Iran. Eighty patients with acute brain injury who met the study inclusion criteria were recruited and randomized into zolpidem and placebo groups. In the zolpidem group, 10 mg zolpidem tablets were gavage twice daily. In the placebo group, a placebo tablet with the same appearance as zolpidem was gavage twice daily for 14 days. The consciousness level of patients was measured daily until the outcome (ICU discharge or expiration) was established. Eventually, a comparative data analysis was conducted to determine zolpidem's efficacy in enhancing consciousness, reducing mechanical ventilation duration, and improving patient outcomes.

The mean GCS score in the zolpidem group was 6.1±2.4 on admission and 11.6±3.8 at the end of the study, compared to 5.9±1.7 on admission and 11.3±2.8 at the end of the study, for the placebo group (p=0.154 and p=0.211, respectively). The mean duration of mechanical ventilation was 24.41±9.14 days in the zolpidem group and 23.16±10.72 days in the placebo group (P=0.529). Twenty-eight patients in the zolpidem group were discharged from ICU, and 12 expired. For the placebo group, 26 patients were discharged from ICU, while 14 were expired (p=0.87). No statistically significant difference was found in any of the measured variables between the two groups.

The results have shown that zolpidem administration had no statistically significant effect on improving the level of consciousness and reducing mechanical ventilation duration and clinical outcomes in acute brain injury patients.

Although nerve block facilitatory effects of dexmedetomidine when used as a perineural adjunct to local anesthetics in supraclavicular brachial plexus blocks are well recognized in multiple studies, but whether this action is at directly on peripheral nerve fibers or is at central level after systemic absorption is unclear. Aim of this study was to evaluate the effect of adding dexmedetomidine 1 microgram/kg to ropivacaine 0.5% in supraclavicular brachial plexus block in terms of duration of analgesia and 24hour cumulative analgesic requirement and to test the hypothesis whether the effect of dexmedetomidine, is due to direct local action on nerve plexus or is centrally mediated after systemic absorption.

105 patients of ASA grade I and II of either sex undergoing upper limb orthopedic surgeries were divided in 3 groups of 35 patients in each group. Group Rc (control group) received supraclavicular block with 30ml of 0.5% ropivacaine and intravenous infusion of 30ml of normal saline; group RDexP received supraclavicular block with 30ml solution of 0.5% ropivacaine+ dexmedetomidine 1mcg/kg and intravenous infusion of 30ml of normal saline; and group RDexIV received supraclavicular block with 30ml of 0.5% ropivacaine and intravenous infusion of 30ml of normal saline solution containing dexmedetomidine 1mcg/kg. Primary outcome was duration of analgesia and 24hour cumulative analgesic requirement.

The demographic data were comparable in all three groups. Duration of analgesia was longest in group RDexP followed by group RDexIV and least in control group. 24hour cumulative analgesic requirement was least in group RDexP and maximum in group R. 2 patients, one from each group RDexP and group RDexIV reported bradycardia and 6 patients from group RDexIV reported hypotension.

We conclude that action of dexmedetomidine is most probably peripheral on brachial plexus nerve fibers directly rather than centrally mediated after systemic absorption.

Cardiac arrest in the operating room (CAO) is a serious accident of often rare epidemiology.

Retrospective, descriptive and analytical study from 2012 to 2021 in the multipurpose intensive care unit of the Cocody University Hospital in Abidjan, including all patients who presented a recovered CAO.

The prevalence was 1.5% (89 out of 5730 admissions). The mean age was 33.5 ± 26 years (13-81). The sex ratio was 0.1. The medical history was mostly hypertension (22.5%). Patients were classified ASA ≥ III (52.8%) for urgent surgery (52.8%) under spinal anesthesia (56.6%). CAO occurred mostly at anesthetic induction (44.3%). The causes were mainly persistent arterial hypotension (54.7%) and hemorrhagic shock (30.2%). Medical CPR was performed in 94.8% of cases in the operating room before transfer to the intensive care unit. The mean duration of LowFlow was 4.5±1.8 minutes (3-12). On admission, the mean Glasgow score was 6.3±4.4 (3-11). Treatment consisted of continued CPR. The mean stay was 3.1±2.9 minutes (1-12). The death rate was 60.4%. ASA class >3, urgent procedure, general anesthesia, presence of NA alone, Gl score ≤ 7, and Low Flow duration> 5 minutes were predictive of mortality (p < 0.05).

strengthening of material resources and continuous training in extreme emergency situations for anesthesia personnel could optimize the prognosis of CAO.

Accurate assessment of intravascular volume status is a vital aspect of management of intensive care unit (ICU) patients. Inferior vena cava (IVC) diameter and IVC collapsibility index have surfaced as promising methods to accurately predict hypovolemia. But no such study has evaluated it’s their utility in postoperative patients.

The study aimed to assess the correlation between ultrasound guided IVC collapsibility index (IVC CI) and CVP for volume status in intensive care unit patients. Hundred spontaneously breathing patients receiving postoperative care in our surgical ICU between November 2019 to march 2021were enrolled into the study. Maximum IVC diameter (IVCdmax) at end-expiration, minimum IVC diameter at end-inspiration (IVCdmin) and IVC CI were measured. Simultaneous CVP recordings were obtained.

A positive correlation was noted between IVC maximum diameter and CVP (p = <0.001) and between IVC Minimum Diameter and CVP. (p = <0.001) A negative correlation between IVC CI and CVP was seen (p = <0.001). Mean IVC CI was highest in the hypovolemic group. The area under the ROC curve (AUROC) for IVC CI predicting hypovolemia was 0.943 (95% CI: 0.9 - 0.986), thus demonstrating excellent diagnostic performance. At a cut off of ≥58.416%, IVC CI predicts hypovolemia with a sensitivity of 93.8%, and a specificity of 84%.

IVC CI can be used to guide fluid therapy due to its excellent diagnostic accuracy in predicting hypovolemia in postoperative patients in ICU.

Unanticipated difficult intubation poses a challenge in routine practice for anaesthesiologists. A preoperative airway evaluation helps in the identification of a difficult airway. Airway assessment with ultrasound is a modality recently being used to predict difficult airway. In this study we evaluate ultrasonography parameters with conventional clinical parameters for predicting difficult airway in adults undergoing elective surgeries.

This cross sectional randomised clinical trial analyses ASA class 1 and 2 adults requiring endotracheal intubation for surgeries under general anaesthesia were enrolled following which Modified Mallampatti score and thyromental distance as well as ultrasound distance to epiglottis (DSE) and distance to hyoid bone (DSHB) were measured and based on Cormack Lehane grading they were categorised into easy and difficult airway groups.

DSE had the highest sensitivity of 90.48% whereas Modified Mallampatti grading had least sensitivity of 66.67%.

The results of this study showed that ultrasonographic measurements at the thyrohyoid and hyoid level have higher sensitivity and specificity than the clinical parameters for airway assessment.

Both ketamine and dexmedetomidine have proven effective in relieving the pain resulting from propofol injection. However, studies comparing them directly are limited. The primary outcome was to compare the incidence of propofol injection pain after dexmedetomidine pretreatment with ketamine pretreatment. Secondary outcome was to study the changes of haemodynamic parameters that arise after the administration of the pretreatment drug till anaesthesia was induced with propofol.

In this randomized, triple blinded, parallel arm single centre study, we compared pre-treatment with dexmedetomidine 0.5mcg/kg (Group A) and ketamine 0.5mg/kg (Group B). Our primary objective was to compare the incidence of propofol injection pain. The McCririck and Hunter scale was used to evaluate the pain. Secondarily, we compared the changes of haemodynamic parameters that arose after the administration of the pre-treatment drug till induction of anaesthesia with propofol.

Among 168 patients evaluated for eligibility, 140 were included for final analysis with 70 patients in each group. The incidence of propofol injection pain in Group A was 74.3% (52/70) and that in Group B was 42.9% (30/70) (p value <0.001). No pain was reported by 25.7% (18/70) and 57.1% (40/70) patients in Group A and B respectively. Mild and moderate to severe pain was experienced by 58.6% and 15.7% patients in Group A, where as it was 40% and 2.9% patients in Group B respectively.

Ketamine leads to a greater reduction in both the frequency and intensity of pain resulting from propofol injection when compared to dexmedetomidine.

Intraoperative stress response and ongoing bleeding at surgical site especially in areas like head and neck can cause serious adverse reactions and affect the postoperative outcome. This study compared the effect of intranasally administered dexmedetomidine (dexmed) in combination with local anesthesia (LA) and local anesthetic alone on quality of surgical field, surgical bleeding and haemodyanamic parameters during functional endoscopic sinus surgery (FESS).

Roller gauge strips dipped in dexmedetomidine were used for nasal packing. Sixty patients undergoing FESS were randomly allocated to receive either intranasal Dexmedetomidine with LA (D group) or intranasal LA alone (L group) via nasal packing 15 min before surgery. The primary objective was to study the quality view of surgical field through the endoscope and the blood loss that occurred while raising the nasal mucosal flap. The secondary objective was to study the intraoperative hemodynamic profile and anesthetic and analgesic requirement during surgery.

Surgical field quality, Blood loss, hemodynamic profile and satisfaction scores of patients and surgeons were significantly better (P< 0.05) in dexmed group.

Patients receiving intranasal dexmed with LA for FESS had better surgical field, surgeon’s satisfaction and minimal hemodynamic fluctuations with lesser blood loss as well as better postoperative comfort and analgesia.

Ropivacaine is an amino-amide local anesthetic, extensively used for peripheral nerve blocks, numerous adjuvants have been added to Ropivacaine to prolong the duration of analgesia.

To compare the effectiveness of adding Dexamethasone to Ropivacaine versus adding Clonidine to Ropivacaine in ultrasound guided supraclavicular brachial plexus block in terms of analgesic duration, onset & duration of sensory and motor blockade.

A prospective randomized single blinded study carried out in 70 patients of ASA grade I and II, aged 20 to 60 years scheduled for elective upper limb orthopedic surgeries. Patients were randomly allocated into two groups, Group RC - patients received 20ml of 0.75% ropivacaine along with 1mcg/kg of clonidine diluted to 2ml of normal saline, Group RD - patients received 20ml of 0.75% ropivacaine along with 8mg of dexamethasone (2ml). Statistical Analysis: Onset & duration of sensorimotor blockade, duration of analgesia was assessed by Unpaired t-test. If p-value <0.05, results were statistically significant & p-value <0.001 were highly significant.

Duration of analgesia is superior and statistically significant in Group RD (1,172.57± 18.37 vs 931.09± 16.3). Onset time for sensory (3.14 ± 1.00 vs 9.71± 1.23) and motor (7.60 ± 1.54 vs 13.66± 1.03) block is rapid in Group RD. Duration of sensory (1,106.57± 20.28 vs 786.26± 31.43) and motor (997.74 ± 24.9 vs 674.57 ± 2.18) block is enhanced in Group RD.

Dexamethasone as an adjuvant to ropivacaine provided superior post-operative analgesia, faster onset and longer duration of sensory and motor blockade.

Propofol is one of the most widely used medications in anesthesia and intensive care. Propofol Intravenous injection is painful for patients at the injection site. The aim of this study was to determine the effect of premedication with oral acetaminophen in prevention of local pain caused by intravenous injection of propofol.

This study was a double-blind randomized controlled trial. Data were collected from July 2020 to July 2021 in Shariati Hospital. All stages of premedication and induction of anesthesia were the same in all three groups of patients. Pb, P500 and P1000 groups (patients with oral placebo, 500 or 1000 mg of oral paracetamol, respectively) received the medication 1 hour before transfer to the operating room.

In this study, 150 patients were included. 44.7% were men, 55.3% women, and mean age of patients was 36.82 ± 10.24. The highest severity of reported pain was in the group of patients receiving placebo. Patients receiving 1 gram of acetaminophen had the lowest reported pain. Patients receiving 500 mg of acetaminophen reported significantly less pain than patients receiving placebo and more pain than patients in the group receiving 1 g of acetaminophen. Age, gender and weight did not have any significant effect on the pain severity.

When compared to placebo, the use of oral acetaminophen as a premedication considerably lowers discomfort induced by intravenous propofol infusion. A dosage of 1 g of oral acetaminophen is more effective than 500 mg in decreasing pain. The level of pain and acetaminophen's pain-relieving effects were not affected by age, gender or weight.

Patient safety is one of the main elements of the quality of health services. Our aim of this study was to compile a complete checklist for the three stages of anesthesia.

This research was a cross-sectional descriptive-analytical study. First, an internet search was conducted in databases to identify checklists related to safe Anesthesia. The WHO Safe Anesthesia Checklist was designated as the main checklist. Then, a brainstorming session was held with experts and according to the determined fields, the initial draft was compiled. Face and content validity were conducted. The reliability of the checklist was measured with Cronbach's alpha and intra class correlation index (ICC) methods.

The initial draft was compiled with 34 items. 29 items scored higher than 0.79 in terms of CVI (content validity index) The value of CVI of 5 items was less than the permissible limit and the edge of the border, which was revised and corrected by the research group. 2 items were returned to the research process according to the survey of experts and their necessity CVR (content validity ratio) (value >0/62) and 3 items were removed from the research process. Cronbach's alpha was calculated as 0.876 for the first evaluator and 0.870 for the second evaluator, and the percentage of agreement between the evaluators was 0.956 (P<0.001).

We developed and evaluated a checklist for the three stages of anesthesia through an evidence-based study. We hope this checklist can reduce and prevent clinical errors.

Direct laryngoscopy necessitates the alignment of the oropharyngeal-laryngeal axis whereas video laryngoscope is an optical vision which doesn’t require alignment. This study aimed to compare direct laryngoscopy with a Macintosh blade to King-Vision Video laryngoscope for endotracheal intubation in patients who were scheduled for elective laproscopic surgeries under general anaesthesia.

In this prospective randomised clinical study,118 adults with ASA I and II requiring endotracheal intubation for laproscopic surgeries under general anaesthesia were enrolled and randomised into either of the two groups by envelope method, Group DL-direct laryngoscope and Group VL-video laryngoscope where they were intubated using direct laryngoscope with Macintosh blade or King Vision videolaryngoscope. The Primary objective was to compare Time to intubate(TTI), Visualization of the laryngeal view by Cormack-Lehane grade and Successful first attempt. Secondary objective was to record the Number of intubation failure, Number of attempts, Change of anaesthesiologist and use of adjunct equipment and the complications such as oropharyngeal trauma, neck pain, dysphagia and hoarseness.

In comparison to group DL (21.67±4.318s), group VL took longer time to intubate (26.21± 4.150s) but had superior glottic vision than DL group(p=0.0177). Compared to DL group (72.4%), the VL (84.5%) patients had their first successful attempt, inspite of 2 failures. Complications such as pharyngeal pain (8.6%vs29.3%), hoarseness (5.2%vs29.3%), Use of adjunct equipment like bougie (19%vs 3.4%) were significantly higher in DL compared to VL group, while oropharyngeal injury, dysphagia, number of attempts and change of anaesthetists were similar in both groups.

In comparison to the Macintosh laryngoscope, the King-vision VideoLaryngoscope took longer to intubate but had clearer glottis visualisation and a higher first-time success rate and can be used as a good teaching tool. In King-vision video laryngoscope, there was less use of auxiliary equipment and fewer complications.

Burnout syndrome (BOS) is a common occupational disease amongst medical physicians; especially anesthesiologists. BOS is known to result in increased expenditure of the healthcare system and decreased patient satisfaction. In order to substitute for good conduct by its medical staff, Tehran University of Medical University established its own guidelines on professionalism as a substitute for professional conduct amongst its personnel. Learning and practicing professionalism is not only a requirement to be competent as a specialist, but also it results in increasing healthcare quality and patient satisfaction. There is a lack of studies on the relationship between BOS and professionalism. Determination of the relationships between professionalism and BOS among TUMS anesthesiology residents.

In this cross-sectional study all anesthesiology residents completed three forms (demographic checklist, Maslach Burnout Inventory (MBI), and professionalism self-conduct). The results were primarily analyzed using STATA 14.0 and relationships were established via linear and binary regression.

About 44 percent of residents met criteria for BOS. The risk of developing BOS was significantly higher for residents who adhered to the principles of respect and altruism and for residents training in one of our surveyed hospitals; whereas the risk of developing BOS would be reduced by increasing age and adherence to the principles of justice Burnout subscales scores concerning emotional exhaustion and personal accomplishment were significantly related with higher self-reported scores of altruism and honesty-integrity respectively.

The chances of developing BOS could be enhanced by inadequate practice in the field of professional ethics. Therefor the importance of learning and competent practice of professionalism must be acknowledged. Age and professional climate were the most important demographic variables related to BOS in anesthesiology residents.

Injury to the Recurrent Laryngeal Nerve is uncommon, but one of the complications of thyroidectomy.
We report a case of 40 years old female, who underwent total thyroidectomy, following which developed recurrent laryngeal nerve injury and vocal cord palsy, which was diagnosed immediately and managed successfully.

Pain is an unpleasant experience and a subjective term that is associated with tissue damage. Cancer patients experience pain for a myriad of reasons, from disease related to treatment causes and unrelated to both of these categories.
Opioids are the mainstay in the treatment of moderate to severe cancer pain. Progressive opioid dose increases can cause opioid-induced hyperalgesia (OIH).
OIH has no definite management, here we present a 47-year-old cancer patient with OIH and her management.

Huge head and neck tumors are known to cause difficult ventilation and difficult intubation. Edentulous mouth can result in difficult mask ventilation. Head and neck tumor resections can also present hemodynamic challenge, due to their proximity to large vessels.
We herein report a clinical case of difficult ventilation due to large parotid tumor in an edentulous patient.

Parapharyngeal tumors often distort the airway anatomy leading to obstruction and hinderance for intubation thus posing a challenge for the anesthetist at securing airway with least damage to the nearby structures.
We present our experience through a series of 5 such cases in children managed successfully using video laryngoscope.
Working in places where availability of advanced airway equipment such as pediatric size fiberoptic is unavailable, a video laryngoscope can help to appropriately assess the airway and prevent disastrous outcomes.