Anaesthesia

Specific reversal agents: Fast and fearless – A new era in anticoagulation care Abhay Bhave Indian Journal of Anaesthesia 2019 63(3):167-168

Novel reversal agents and laboratory evaluation for direct-acting oral anticoagulants (DOAC): An update Shagun B Shah, Akhilesh Pahade, Rajiv Chawla Indian Journal of Anaesthesia 2019 63(3):169-181 Novel oral anticoagulants (NOACs) are no longer “novel” but their reversal agents definitely are. Although NOACs enjoy high clinical efficacy, monitoring and reversal of their effect is a challenge which this review attempts to surmount. Ideally, for NOAC activity measurement, specific anti-Factor IIa levels and anti -Factor Xa levels should be monitored (chromogenic assays), but such tests are not readily available. Modifications of the existing coagulation tests catering to this unmet need for quantification of DOAC activity have been reviewed. The available United States Food and Drug Administration (FDA) approved reversal agents, idarucizumab for dabigatrin and andexanet alfa for anti-Xa direct acting oral anticoagulants have given promising results but are prohibitively priced. Medline, Embase, and Scopus databases were thoroughly searched for clinical trials on laboratory investigations and specific as well as non-specific reversal-agents for DOACs.

Efficacy of local wound infiltration analgesia with ropivacaine and dexmedetomidine in tubercular spine surgery – A pilot randomised double-blind controlled trial Medha Mohta, Anju Rani, Ashok Kumar Sethi, Anil Kumar Jain Indian Journal of Anaesthesia 2019 63(3):182-187 Background and Aims: Regional analgesic techniques are difficult to use in tubercular spine patients due to distorted spinal anatomy and presence of infection. This study was conducted with the aim to evaluate analgesic efficacy of local wound infiltration before wound closure in tubercular spine patients. Methods: This pilot randomised double-blind controlled study was conducted in 32 American Society of Anesthesiologists I-III patients, age ≥15 years, undergoing elective surgery for spinal tuberculosis. All the patients received general anaesthesia using standard technique and intravenous morphine for intraoperative analgesia. They received wound infiltration with either normal saline (group C) or local infiltration analgesia with 0.375% ropivacaine 3 mg/kg, adrenaline 5 μg/mL and dexmedetomidine 1 μg/kg in a total volume of 0.8 mL/kg (group LIA) before wound closure. Patient-controlled analgesia using intravenous morphine provided postoperative analgesia. The primary objective was to study 24-h morphine consumption, whereas the secondary objectives included pain scores, complications and patient satisfaction. Repeated measures analysis of variance, Chi-square test and Mann–Whitney U test were used for statistical analysis. Results: Morphine requirement was lower in group LIA (6.7 ± 2.7 mg) than in group C (27.7 ± 7.9 mg);P < 0.001. Group LIA also had lower pain scores (P < 0.001), longer time to rescue analgesic (P < 0.001), better patient satisfaction to pain relief (P = 0.001) and lower incidence of postoperative nausea and vomiting than group C. Conclusion: Wound infiltration with ropivacaine, adrenaline and dexmedetomidine before wound closure provided good postoperative analgesia with lower morphine requirement.

A randomised controlled comparison of video versus instructor-based compression only life support training Shahna Ali, Manazir Athar, Syed Moied Ahmed Indian Journal of Anaesthesia 2019 63(3):188-193 Background and Aims: Sudden cardiac deaths remain a major health problem worldwide. Most of these cases generally involve out of hospital cardiac arrest, making the role of bystander resuscitation very crucial. In the developing countries, illiteracy and scarcity of health professionals is a great barrier to cardiopulmonary resuscitation (CPR) training. Video-based CPR training can offer an easily accessible modality in these situations. Hence, this study was conducted with an aim to assess the efficacy of video-based training in comparison to the traditional instructor-based CPR training in layman. Methods: This prospective cross-over observational study included 109 undergraduate university students attending voluntary resuscitation training and were randomly divided into two groups of video-based demonstration (VBD) and instructor-based demonstration (IBD) of compression only life support (COLS). They were then assessed for psychomotor skill development (Laerdal Simpad Plus Q-CPR) and perception about the quality of training methodology as primary and secondary objectives, respectively. Results: Population characteristics were similar in both the groups. In the VBD, scene safety was performed by 95.2% and call for help by 97.6%, and by 76.1% each in the IBD group (P < 0.05). Response to compression time (RCT) was significantly shorter in VBD (35 ± 9 sec) as compared to IBD (54 ± 14 sec) (P < 0.001). However, the proportion of participants performing response check, correct site identification, and other parameters were comparable. Conclusion: Video-based COLS training significantly decreased the RCT by 35% compared to traditional instructor-based training. However, other features of high-quality CPR remain comparable.

Prediction of outcomes in chest trauma patients using chest trauma scoring system: A prospective observational study Minal Harde, G Aditya, Sona Dave Indian Journal of Anaesthesia 2019 63(3):194-199 Background and Aims: Prognostication of chest trauma patients by scoring systems is of vital importance to predict morbidity and mortality. We aimed to predict outcomes in chest trauma patients using chest trauma scoring system (CTS) in Indian patients. Methods: This was a prospective observational study done in a trauma care centre at a tertiary care teaching public hospital. CTS was calculated by scores of age, severity of pulmonary contusion, number of rib fractures and presence of bilateral rib fractures. Final CTS ranges from 2 to 12. We evaluated CTS to predict outcome that is mortality as primary objective and development of complications like pneumonia and need for ventilator support as secondary objective in Indian population. Results: Data were collected from 30 patients and they were divided into two groups, CTS <5 (15) and CTS ≥5 (15). High CTS ≥5 was statistically significantly associated with high incidence of pneumonia (P = 0.046), increased requirement of mechanical ventilation (P = 0.025) and mortality (P = 0.035) in chest trauma. Area under the ROC for mortality shows that the test is acceptable (0.75) and at CTS score 5.5 maximum sensitivity is 87.5% and specificity is 68%. Conclusion: This study concludes that a CTS ≥5 is associated with poor outcomes. This scoring system may be used to identify patients at risk of complications and institute early intensive focussed care.

Ultrasound-guided erector spinae plane block for postoperative analgesia in modified radical mastectomy: A randomised control study Swati Singh, Gunjan Kumar, Akhileshwar  Indian Journal of Anaesthesia 2019 63(3):200-204 Background and Aims: Several locoregional techniques have been described for providing postoperative analgesia after breast surgery. The optimal technique should be easy to perform, reproducible and provide good analgesia. This randomised control study was designed to evaluate the postoperative analgesic effect of ultrasound-guided erector spinae plane (US-guided ESP) block for modified radical mastectomy (MRM) surgery. Methods: A total of 40 females belonging to American Society of Anesthesiologists' 1 or 2 posted for MRM were randomly allocated into Group 1 (control group) and group 2 (ESP group). Patients in Group 1 received only general anaesthesia (GA) and were managed for pain postoperatively according to routine protocol, while group 2 (ESP group) patients received unilateral US-guided ESP block preoperatively (20 mL 0.5% bupivacaine to the operating side) followed by GA. The primary objective of study was to record postoperative 24 h cumulative morphine requirement. Differences between the two groups were analyzed using the Mann–Whitney U-test or a two-tailed Student's t-test. Results: Postoperative morphine consumption was found to be significantly less in patients receiving US-guided ESP block compared to control group (1.95 ± 2.01 mg required in ESP group vs 9.3 ± 2. 36 mg required in control group, P value = 0.01)). All the patients in control group required supplemental morphine postoperatively compared to only two patients requiring that in US-guided ESP block group (P < 0.01). Conclusion: US-guided ESP block when given prior to MRM surgery provided effective postoperative analgesia. CTRI registration no. - CTRI/2018/03/012712 registered in the clinical trial registry, India.

A comparative evaluation of pre-emptive versus post-surgery intraperitoneal local anaesthetic instillation for postoperative pain relief after laparoscopic cholecystectomy: A prospective, randomised, double blind and placebo controlled study Prabhu Gnapika Putta, Hemalatha Pasupuleti, Aloka Samantaray, Hemanth Natham, Mangu Hanumantha Rao Indian Journal of Anaesthesia 2019 63(3):205-211 Background and Aims: Intraperitoneal local anaesthetic instillation (IPLAI) reduces postoperative pain and analgesic consumption effectively but the timing of instillation remains debatable. This study aims at comparing pre-emptive versus post-surgery IPLA in controlling postoperative pain after elective laparoscopic cholecystectomy. Methods: Ninety patients belonging to American Society of Anesthesiologists physical status I or II were randomly assigned to receive IPLAI of either 30 ml of normal saline (C) or 30 ml of 0.5% bupivacaine at the beginning (PE) or at the end of the surgery (PS) using a double-dummy technique. The primary outcome was the intensity of postoperative pain by visual analogue scale score (VAS) at 30 minute, 1, 2, 4, 6, 24 hours after surgery and time to the first request for analgesia. The secondary outcomes were analgesic request rate in 24 hours; duration of hospital stay and time to return to normal activity. Data were compared using analysis of variance, Kruskal-Wallis or Chi-square test. Results: For all predefined time points, VAS in group PE was significantly lower than that in groups C (P < 0.05). The time to first analgesic request was shortest in group C (238.0 ± 103.2 minutes) compared to intervention group (PE, 409.2 ± 115.5 minutes; PS, 337.5 ± 97.5 minutes;P < 0.001). Time to attain discharge criteria was not statistically different among groups. Conclusion: Pre-emptive intraperitoneal local anaesthetic instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and early resumption of normal activity in comparison to post surgery IPLAI and control.

Haemodynamic changes during prone positioning in anaesthetised chronic cervical myelopathy patients Nitin Manohar, Venkatapura J Ramesh, Muthuchellappan Radhakrishnan, Dhritiman Chakraborti Indian Journal of Anaesthesia 2019 63(3):212-217 Background and Aims: Anaesthetised patients, when positioned prone, experience hypotension and reduction in cardiac output. Associated autonomic dysfunction in cervical myelopathy patients predisposes them to haemodynamic changes. The combined effect of prone positioning and autonomic dysfunction in anaesthetised patients remains unknown. Methods: Thirty adult chronic cervical myelopathy patients, aged 18-65 years with Nurick grade ≥2 were recruited in this prospective observational study. Heart rate, mean blood pressure, cardiac output, stroke volume, total peripheral resistance and stroke volume variation were measured using NICOM®monitor. Data were collected in supine before anaesthetic induction (baseline), 2 minutes after induction, 2 minutes after intubation, before and after prone positioning and every 5 minutes thereafter until skin incision. Repeated measures analysis of variance (ANOVA) was used to analyse the haemodynamic parameters across the time points. Bivariate Spearman's correlation was used to find factors associated with blood pressure changes. A P value <0.05 was kept significant. Results: Cardiac output during the entire study period remained stable (P = 0.186). Sixty percent of the patients experienced hypotension. At 15 and 20 minutes after prone positioning, mean blood pressure decreased (P = 0.001), stroke volume increased (P = 0.001), and heart rate and total peripheral resistance decreased (P < 0.001, P= 0.001, respectively). These changes were significant when compared to pre-prone position values. Number of levels of spinal cord compression positively correlated with the incidence of hypotension. Conclusion: Cervical myelopathy patients experienced hypotension with preserved cardiac output in prone position due to a reduction in total peripheral resistance. Hypotension correlated with the number of levels of spinal cord compression.

I-Gel as an intubation conduit: Comparison of three different types of endotracheal tubes Nitin Choudhary, Abhijit Kumar, Amit Kohli, Sonia Wadhawan, Poonam Bhadoria Indian Journal of Anaesthesia 2019 63(3):218-224 Background and Aims: I-Gel®, a novel SAD has been introduced as a ventilating device but has widely gained popularity as conduit for intubation. Unlike intubating laryngeal mask airway (ILMA), I-Gel® does not have an endotracheal tube specially designed for it. Hence the aim of this study was to compare the rate of successful intubation via I-Gel®using three different types of endotracheal tubes. Methods: We randomised 75 American Society of Anesthesiologists (ASA) physical status I and II patients, between the age group 18-60 years of either sex undergoing elective surgery under general anaesthesia into three groups on the basis of endotracheal tube (ETT), used for intubation via I-Gel®: Group P (Polyvinyl chloride ETT), Group I (Intubating laryngeal mask airway ETT), Group F (flexometallic ETT). After following the standard induction protocol, appropriate size I Gel®was inserted in all patients. Thereafter group specific ETT was inserted via I-Gel®. We recorded and compared the time taken for successful intubation, the success rate, number of attempts taken, manoeuvres used, and complications among three different types of ETT. Quantitative variables were compared using Kruskal Wallis test and the qualitative variables were compared using Chi-square test. Results: The time taken for successful intubation was least in group P (10.51 ± 3.82 seconds). Group P also had the highest first attempt (68%) and overall rate of successful intubation (88%). Conclusion: PVC ETT had highest first attempt success rate and required minimum time for endotracheal intubation via I-Gel®when compared to ILMA ETT and Flexible ETT.

Comparison of bispectral index targeted end-tidal concentration of desflurane during three phases of orthotopic liver transplantation Gyanendra Kumar, Nitin Sethi, Deepanjali Pant, Jayashree Sood, Amarjeet Singh, Shashank Pandey, Amitabh Dutta Indian Journal of Anaesthesia 2019 63(3):225-230 Background and Aims: Reduced inhalational anaesthetic requirement in end-stage liver disease during living donor orthotopic liver transplantation (LD-OLT) is due to increased endogenous opioids. This study evaluated the changes in bi-spectral index (BIS) monitored end-tidal desflurane (ETDes) requirements during ‘dissection’, ‘anhepatic’, and ‘neohepatic’ phases of LD-OLT. Methods: This prospective, cohort study included 40 adults undergoing LD-OLT under general anaesthesia (GA). All patients received BIS-guided desflurane GA. ETDesrequirements in three phases of LD-OLT (primary objective); relationship between inhalational anaesthetic requirements and severity of liver disease; and effect of changes in mean arterial pressure (MAP) and body temperature on ETDesconcentration for all three phases were also evaluated. Results: ETDesduring the ‘dissection’ phase (2.92 ± 0.65%) was > ‘anhepatic’ (2.68 ± 0.85%, P= 0.049) and ‘neohepatic’ phases (2.58 ± 0.71%, P= 0.005). Patients with model of end-stage liver disease (MELD) score < 20 returned significantly greater ETDesthan those with MELD score ≥20 during the ‘dissection’ (MELD <20: 3.11 ± 0.49%; MELD ≥20: 2.58 ± 0.77%, P= 0.01) and ‘anhepatic’(MELD <20: 2.96 ± 0.76%; MELD ≥20: 2.17 ± 0.79%, P= 0.003) phases. A positive correlation was observed between ETDes(r = 0.584, P= 0.001) and temperature in the ‘dissection’ phase only. Conclusion: In patients undergoing LD-OLT, BIS monitoring guidance of depth of desflurane GA suggests lower desflurane requirements during ‘anhepatic’ and the ‘neohepatic’ phase of surgery. Also, the desflurane requirement is greater in patients with lesser severity of liver disease.