Search results for: sevoflurane

Authors: Jong Yeop Kim, Sung Young Park, Dae Hee Kim, Han Bum Joe, Ji Young Yoo, Jong Bum Choi, Sook Young Lee

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Emergence agitation (EA) is commonly reported adverse events after sevoflurane anesthesia in pediatric patients. The efficacy of prophylactic remifentanil, one of mu opioid agonist, in preventing EA is controversial. This meta-analysis assessed the effectiveness of remifentanil to decrease the incidence of EA from sevoflurane anesthesia in children. We searched for randomized controlled trials comparing sevoflurane alone anesthesia with sevoflurane and remifentanil anesthesia to prevent EA in the Cochrane Library, Embase, Pubmed, and KoreaMed, and included 6 studies with 361 patients. The number of patients of reporting EA was summarized using risk ratio (RR) with 95% confidence interval (CI), with point estimates and 95CIs derived from a random effects Mantel-Haenszel method. Overall incidence of EA was about 41%. Compared with sevoflurane alone anesthesia, intravenous infusion of remifentanil with sevoflurane significantly reduced the incidence of EA (RR 0.53, 95% CI 0.39-0.73, P < 0.0001), (heterogeneity, I2 = 0, P = 0.42). This meta-analysis suggested that continuous infusion of remifentanil could be effective in decreasing the EA of about 47% after sevoflurane anesthesia. However, considering limitations of the included studies, more randomized controlled studies are required to verify our results.

Keywords: emergence agitation, meta-analysis, remifentanil, pediatrics

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Authors: Ki Hwa Lee, Eunsu Kang, Jae Hong Park

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Background: Interventional neuroradiology (INR) has been a rapidly growing and evolving neurosurgical part during the past few decades. Sevoflurane and propofol are both suitable anesthetics for INR procedure. Monitoring of depth of anesthesia is being used very widely. SEDLine™ monitor, a 4-channel processed EEG monitor, uses a proprietary algorithm to analyze the raw EEG signal and displays the Patient State Index (PSI) values. There are only a fewer studies examining the PSI in the neuro-anesthesia. We aimed to investigate the difference of PSI values and hemodynamic variables between sevoflurane and propofol anesthesia during INR procedure. Methods: We reviewed the medical records of patients who scheduled to undergo embolization of non-ruptured intracranial aneurysm by a single operator from May 2013 to December 2014, retrospectively. Sixty-five patients were categorized into two groups; sevoflurane (n = 33) vs propofol (n = 32) group. The PSI values, hemodynamic variables, and the use of hemodynamic drugs were analyzed. Results: Significant differences were seen between PSI values obtained during different perioperative stages in both two groups (P < 0.0001). The PSI values of propofol group were lower than that of sevoflurane group during INR procedure (P < 0.01). The patients in propofol group had more prolonged time of extubation and more phenylephrine requirement than sevoflurane group (p < 0.05). Anti-hypertensive drug was more administered to the patients during extubation in sevoflurane group (p < 0.05). Conclusions: The PSI can detect depth of anesthesia and changes of concentration of anesthetics during INR procedure. Extubation was faster in sevoflurane group, but smooth recovery was shown in propofol group.

Keywords: interventional neuroradiology, patient state index, propofol, sevoflurane

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Authors: Hala Demerdash, Ola M. Zanaty, Emad Eldin Arida

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Background: This study investigated the micoRNA expression changes induced by Sevoflurane and Propofol and their effects on liver functions. Patients and methods: The study was designed as randomized controlled study, carried out on 200 adult patients, scheduled for major surgeries under general anesthesia (GA). Patients were randomly divided into four groups; groups SC and PC included chronic hepatitis C (CHC) patients where SC group are patients receiving Sevoflurane, and PC group are patients receiving Propofol anesthesia. While S and P groups included non- hepatitis patients; S group are patients receiving Sevoflurane and P group are patients receiving Propofol. Anesthesia in Group S and SC patients was maintained by sevoflurane, while anesthesia in Group P and PC patients was maintained by propofol infusion. Blood samples were analyzed for PT, PTT and liver enzymes. Serum samples were analyzed for microRNA before and after surgery. Results: Results show miRNA-122 and miRNA-21 were absent in serum of S and P groups in pre-operative samples. However, they were expressed in SC and PC groups. In post-operative samples; miRNA-122 revealed an increased expression in all groups; with more exaggerated response in SC group. On the other hand miRNA-21 revealed increased expression in both SC and PC groups; a slight expression in S group with absent expression in P group. There was a post-operative negative correlation between miR-122 and ALT (r=-0.46) in SC group and (r=-0.411) in PC group and positive correlation between ALT and miR-21 (r=0.335) in SC group and (r=0.379) in PC group. The amount of blood loss was positively correlated with miR-122 (r=0.366) in SC group and (r=0.384) in PC group. Conclusion: Propofol anesthesia is safer than Sevoflurane anesthesia in patients with CHC. Sevoflurane and Propofol anesthesia affect miRNA expression in both CHC and non-hepatitis patients.

Keywords: anesthesia, chronic hepatitis C, micoRNA, propofol, sevoflurane

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Authors: Vidhi Chandra, Arshpreet Singh Grewal

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A five-year-old male child born from non-consanguineous marriage, who presented with complaints of growth retardation and no appreciable increase in the penile size since birth and he was posted for de-gloving of penis with dissection of corpora under anaesthesia. After thorough preoperative evaluation it was revealed that patient had peculiar facial dysmorphism that of Robinow Syndrome, high arched palate, Mallampati grade III, mesomelic limbs, scoliotic spine and short stature. All routine investigation were within normal limit, electrocardiography (ECG) and 2D-Echocardiography (ECHO) were normal. In antero-posterior roentgenogram chest showed butterfly and hemivertebrae at multiple levels. The patient was considered to be ASA II. On the day of surgery after ensuring fasting of 6 hours, patient was taken in operation theatre, all standard ASA monitoring was done with ECG, non-invasive blood pressure, peripheral oxygen saturation (SpO2) and body temperature. The patient was pre-oxygenated with 100% oxygen with anatomical face mask. General anaesthesia was induced with Sevoflurane 1-8%, and airway was secured with an appropriate size supraglottic airway and anaesthesia was maintained with nitrous oxide and oxygen in 1:1 ratio along with sevoflurane 2%. An ultrasound guided caudal block was given owing to the skeletal deformities making it difficult even under USG guidance. Post operatively patient was given supportive care with proper hydration, antibiotics, anti-inflammatory and analgesics. He was discharged the next day and followed up weekly for a month. DISCUSSION Robinow syndrome is genetically inherited as autosomal dominant, autosomal recessive or heterogenous disorder involving tyrosine kinase ROR2 gene located on chromosome 9. It has low incidence with no preponderance for any gender. Though intelligence is normal but developmental delay and mental retardation occurs in 20%cases

Keywords: Robinow Syndrome, dwarfism, paediatric, anaesthesia

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Authors: Itee Chowdhury, Shikha Modi

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Introduction: Cancer is beginning to outpace cardiovascular disease as a cause of death affecting every major organ system with profound implications for perioperative management. Breast cancer is the most common cancer in women in India, accounting for 27% of all cancers. The small changes in analgesic management of cancer patients can greatly improve prognosis and reduce the risk of postsurgical cancer recurrence as opioid-based analgesia has a deleterious effect on cancer outcomes. Shortened postsurgical recovery time facilitates earlier return to intended oncological therapy maximising the chance of successful treatment. Literature reveals that the role of BIS since FDA approval has been assessed in various types of surgeries, but clinical data on its use in oncosurgical patients are scanty. Our study focuses on the role of BIS-guided anaesthesia for breast cancer surgery patients. Methods: A prospective randomized controlled study in patients aged 36-55years scheduled for modified radical mastectomy was conducted in 51 patients in each group who met the inclusion and exclusion criteria, and randomization was done by sealed envelope technique. In BIS guided anaesthesia group (B), sevoflurane was titrated to keep the BIS value 45-60, and thereafter if the patient showed hypertension/tachycardia, an opioid was given. In standard anaesthesia care (group C), sevoflurane was titrated to keep MAC in the range of 0.8-1, and fentanyl was given if the patient showed hypertension/tachycardia. Intraoperative opioid consumption was calculated. Postsurgery recovery characteristics, including Aldrete score, were assessed. Patients were questioned for pain, PONV, and recall of the intraoperative event. A comparison of age, BMI, ASA, recovery characteristics, opioid, and VAS score was made using the non-parametric Mann-Whitney U test. Categorical data like intraoperative awareness of surgery and PONV was studied using the Chi-square test. A comparison of heart rate and MAP was made by an independent sample t-test. #ggplot2 package was used to show the trend of the BIS index for all intraoperative time points for each patient. For a statistical test of significance, the cut-off p-value was set as <0.05. Conclusions: BIS monitoring led to reduced opioid consumption and early recovery from anaesthesia in breast cancer patients undergoing MRM resulting in less postoperative nausea and vomiting and less pain intensity in the immediate postoperative period without any recall of the intraoperative event. Thus, the use of a Bispectral index monitor allows for tailoring of anaesthesia administration with a good outcome.

Keywords: bispectral index, depth of anaesthesia, recovery, opioid consumption

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Authors: Jong Yeop Kim, Ji Eun Kim, Hyun Jeong Kwak, Sook Young Lee

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Background: This prospective, randomized, controlled study was performed to evaluate the usefulness of the McGrath VL compared to Macintosh laryngoscopy in children with expected normal airway during endotracheal intubation, by comparing the time to intubation and ease of intubation. Methods: Eighty-four patients, aged 1-10 years undergoing endotracheal intubation for elective surgery were randomly assigned to McGrath group (n = 42) or Macintosh group (n = 42). Anesthesia was induced with propofol 2.5-3.0 mg/kg and sevoflurane 5-8 vol%. Orotracheal intubation was performed 2 minutes after injection of rocuronium 0.6 mg/kg with McGrath VL or Macintosh laryngoscope. The primary outcome was time to intubation. The Cormack and Lehane glottic grade, intubation difficulty score (IDS), and success rate of intubation were assessed. Hemodynamic changes also were recorded. Results: Median time to intubation [interquartile range] was not different between the McGrath group and the Macintosh group (25.0 [22.8-28.3] s vs. 26.0 [24.0-29.0] s, p = 0.301). The incidence of grade I glottic view was significantly higher in theMcGrath group than in the Macintosh group (95% vs. 74%, p = 0.013). Median IDS was lower in the McGrath group than in the Macintosh group (0 [0-0] vs. 0 [0-1], p = 0.018). There were no significant differences in success rate on intubation or hemodynamics between the two groups. Conclusions: McGrath VL provides better laryngeal views and lower IDS, but similar intubation times and success rates compared to the Macintosh laryngoscope in children with the normal airway.

Keywords: intubation, Macintosh laryngoscopy, Mcgrath videolaryngoscopy, pediatrics

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Authors: S. Öcal, A. Erakgün, E. Yüksel, M. N. Deniz, E. Erhan, A. Çertuğ

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Background: Emergence agitation (EA) is defined as a dissociated state of consciousness during the early post-anesthesia period in which the child is inconsolable, irritable, uncompromising or uncooperative, typically thrashing, crying, moaning, or incoherent, and not recognizing or identifying familiar and known objects or people. Some studies found preoperative parental anxiety to be a predictor of EA. Methods: Seventy-four children, between the ages of 3-12 undergoing adenoidectomy/tonsillectomy at Ege University Hospital, were studied. Anesthesia was induced and maintained using 2% sevoflurane in 50% oxygen and 50% air following a premedicative dose of 0.5mg/kg oral midazolam. After the children were taken into the operating theater, the mothers were given the State-Trait Anxiety Inventory (STAI) questionnaire. To evaluate EA, Post Anesthetic Emergence Delirium (PAED) score of the children were noted every 10min during the first 30min of the postoperative period. EA was defined with a highest PAED score of ≥ 10, and non-EA with a highest PAED score of ≤ 9. Results: In this study, the incidence of postoperative EA was 31% (34% under the age of 6 and 19% over). Mothers of children with EA were found not to be significantly more anxious on STAI compared to mothers of non-EA children. Conclusions: Contrary to some earlier studies, we were unable to find an association between preoperative parental anxiety and postoperative EA.

Keywords: parental anxiety, emergence agittion, Post Anesthetic Emergence Delirium, anesthesia

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Authors: T. C. Ng, R. Radzi, T. K. Ng, H. C. Chen

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The analgesic effects of lidocaine-bupivacaine block in cats undergoing routine orchiectomy were determined in this controlled, randomized, and blinded study. Twelve cats were randomly assigned to two groups. Cats in local block group received subcutaneous infiltration of 1 mg/kg of 2% lidocaine and 1 mg/kg of 0.5% bupivacaine into the scrotal sac. Cats in control group received equivolume of saline. Both groups were induced with mixture of ketamine (15 mg/kg) and acepromazine (0.1 mg/kg) intramuscularly and maintained on sevoflurane via facemask. Non-invasive blood pressures (BP), heart (HR), and respiratory rate (RR) were measured intra-operatively at specific events. Post-operatively, all cats received meloxicam, 0.2 mg/kg subcutaneously. Pain scores were determined at 4, 8, and 24 hours postoperatively. Mechanical pressure thresholds (MPT) at the perineum and metatarsus were determined at 2, 4, 8, and 24 hours postoperatively. Intra-operatively, the BP and HR tended to be higher in the control group. The increment in HR peaked during traction and autoligation of the spermatic cord in the control group. There was no treatment difference in RR. Post-operatively, pain scores in the group given local blocks were lower than the control group at 4 hour post-operation. There was no treatment difference in the post-operative HR, RR, BP and MPT values. In conclusion, subcutaneous infiltration of lidocaine-bupivacaine into the scrotal sac before orchiectomy improved intra-operative hemodynamic stability and provided better analgesia up to 4 hours post-surgery.

Keywords: analgesia, bupivacaine, cat, lidocaine, local block, orchiectomy

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Authors: In Kyong Yi, Yun Jeong Chae, Jihoon Hwang, Sook-Young Lee, Jong-Yeop Kim

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Background: Pentax airway scope (AWS) is a recently developed video laryngoscope for use in both normal and difficult airways, providing a good laryngeal view. The purpose of this randomized noninferior study was to evaluate the efficacy of the Pentax-AWS regarding intubation time, laryngeal view and ease of intubation in pediatric patients with normal airway, compared to Macintosh laryngoscope. Method: A total of 136 pediatric patients aged 1 to 10 with American Society of Anesthesiologists physical status I or II undergoing general anesthesia required orotracheal intubation were randomly allocated into two groups: Macintosh laryngoscope (n =68) and Pentax AWS (n=68). Anesthesia was induced with propofol, rocuronium, and sevoflurane. The primary outcome was intubation time. Cormack-Lehane laryngeal view grade, application of optimal laryngeal external manipulation (OELM), intubation difficulty scale (IDS), intubation failure rate and adverse events were also measured. Result: No significant difference was observed between the two groups regarding intubation time (Macintosh; 23[22-26] sec vs. Pentax; 23.5[22-27.75] sec, p=0.713). As for the laryngeal view grade, the Pentax group showed less number of grade 2a or higher grade cases compared to the Macintosh group (1/2a/2b/3; 52.9%/41.2%/4.4%/1.5% vs. 98.5%/1.5%/0%/0%, p=0.000). No optimal laryngeal external manipulation application was required in the Pentax group (38.2% vs. 0%, p=0.000). Intubation difficulty scale resulted in lower values for Pentax group (0 [0-2] vs. 0 [0-0.55], p=0.001). Failure rate was not different between the two groups (1.5% vs. 4.4%, p=0.619). Adverse event-wise, slightly higher incidence of bleeding (1.5% vs. 5.9%, p=0.172) and teeth injury (0% vs. 5.9%, p=0.042) occurred in the Pentax group. Conclusion: In conclusion, Pentax-AWS provided better laryngeal view, similar intubation time and similar success rate compared with Macintosh laryngoscope in children with normal airway. However, the risk of teeth injury might increase and warrant special attention.

Keywords: Pentax-AWS, pediatric, video laryngoscope, intubation

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Authors: Amrit Vasdev, Edwin Rho, Gurinder Vasdev

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Robotic surgery has enabled a new spectrum of minimally invasive breast reconstruction by improving visualization, surgeon posturing, and improved patient outcomes.1 The DaVinci robot system can be utilized in nipple sparing mastectomies and reconstructions. The process involves the insufflation of the subglandular space and a dissection of the mammary gland with a combination of cautery and blunt dissection. This case outlines a 35-year-old woman who has a long-standing family history of breast cancer and a diagnosis of a deleterious BRCA2 genetic mutation. She has decided to proceed with bilateral nipple sparing mastectomies with implants. Her perioperative mammogram and MRI were negative for masses, however, her left internal mammary lymph node was enlarged. She has taken oral contraceptive pills for 3-5 years and denies DES exposure, radiation therapy, human replacement therapy, or prior breast surgery. She does not smoke and rarely consumes alcohol. During the procedure, the patient received a standardized anesthetic for out-patient surgery of propofol infusion, succinylcholine, sevoflurane, and fentanyl. Aprepitant was given as an antiemetic and preoperative Tylenol and gabapentin for pain management. Concerns for the patient during the procedure included CO2 insufflation into the subcutaneous space. With CO2 insufflation, there is a potential for rapid uptake leading to severe acidosis, embolism, and subcutaneous emphysema.2To mitigate this, it is important to hyperventilate the patient and reduce both the insufflation pressure and the CO2 flow rate to the minimal acceptable by the surgeon. For intraoperative monitoring during this 6-9 hour long procedure, it has been suggested to utilize an Arterial-Line for end-tidal CO2 monitoring. However, in this case, it was not necessary as the patient had excellent cardiovascular reserve, and end-tidal CO2 was within normal limits for the duration of the procedure. A BIS monitor was also utilized to reduce anesthesia burden and to facilitate a prompt discharge from the PACU. Minimal Invasive Robotic Surgery will continue to evolve, and anesthesiologists need to be prepared for the new challenges ahead. Based on our limit number of patients, robotic mastectomy appears to be a safe alternative to open surgery with the promise of clearer tissue demarcation and better cosmetic results.

Keywords: anesthesia, mastectomies, robotic, hypercarbia

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Authors: Aarti Agarwal, Ajmal Khan

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Background and Objective: Breathing difficulty is most distressing symptom for the patient and their caregivers providing palliative care to individuals with advanced malignancy. It needs to be tackled effectively and sometimes preemptively to provide relief from respiratory obstruction. Interventional procedures like tracheal stenting are becoming increasingly popular as a part of palliation for respiratory symptoms. We present a case of esophageal tumor earlier stented by Gastroenterologist to maintain esophageal patency, but the tumor outgrew to produce tracheal infiltration and thereby causing airway obstruction. Method and Result: 62-year-old man presented with unresectable Carcinoma oesophagus with inability to swallow. A metallic stent was placed by the gastroenterologist, to maintain esophageal patency and enable patient to swallow. Two months later, the patient returned to hospital in emergency with respiratory distress. CT neck and thorax revealed tumor infiltration through posterior tracheal wall. Lower extent of the tumor was till 1 cm above the carina. Airway stenting with Tracheo bronchial stent with Y configuration was planned under general anaesthesia with airway blocks. Superior Laryngeal Nerve Block, Glossopharyngeal block and Trans tracheal infiltration of local anaesthetics were performed. The patient was sedated with Fentanyl, Midazolam and propofol infusion but was breathing spontaneously. Once the rigid bronchoscope was placed inside trachea, breathing was supported with oxygen and sevoflurane. Initially, the trachea was cleared of tumor by coring. After creating space, tracheal stent was positioned and deployed. After stent placement patient was awakened, suctioned and nebulized. His respiratory stridor relieved instantaneously and was shifted to recovery. Conclusion: Airway blocks help in decreasing the incidence and severity of coughing during airway instrumentation thereby help in proper stent placement. They also reduce the requirement of general anaesthetics and hasten the post stenting recovery. Airway stent provided immediate relief to patient from symptoms of respiratory difficulty. Decision for early tracheal stenting may be taken for a select group of patients with high propensity for local spread, thereby avoiding respiratory complications and providing better quality of life in patients with inoperable malignancy.

Keywords: tracheal stent, respiratory difficulty, esophageal tumor, anaesthetic management

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Authors: L. Kashyap, S. Jha, D. Shende, V. K. Mohan, P. Khanna, A. Aravindan, S. Kashyap, L. Singh, S. Aggarwal

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Obesity is associated with a chronic inflammatory state. During surgery, there is an interplay between anaesthetic and surgical stress vis-a-vis the already present complex immune state. Moreover, the postoperative period is dictated by inflammation, which is crucial for wound healing and regeneration. An excess of inflammatory response might hamper recovery besides increasing the risk for infection and complications. There is definite evidence of the immunosuppressive role of inhaled anaesthetic agents. This immune modulation may be brought into effect directly by influencing the innate and adaptive immunity cells. The effects of propofol on immune mechanisms in has been widely elucidated because of its popularity. It reduces superoxide generation, elastase release, and chemotaxis. However, there is no unequivocal proof of one’s superiority over the other. Hence, an anaesthetic regimen with lesser inflammatory potential and specific to the obese patient is needed. OBESITA trial protocol (2019) by Sousa and co-workers in progress aims to test the hypothesis that anaesthesia with sevoflurane results in a weaker proinflammatory response compared to propofol, as evidenced by lower IL-6 and other biomarkers and an increased macrophage differentiation into M2 phenotype in adipose tissue. IL-6 was used as the objective parameter to evaluate inflammation as it is regulated by both surgery and anesthesia. It is the most sensitive marker of the inflammatory response to tissue damage since it is released within minutes by blood leukocytes. We hypothesized that maintenance of anaesthesia with propofol would lead to less inflammation than that with desflurane. Aims: The effect of two anaesthetic techniques, total intravenous anaesthesia (TIVA) with propofol and desflurane, on surgical stress response was evaluated. The primary objective was to compare serum interleukin-6 (IL-6) levels before and after surgery. Methods: In this prospective single-blinded randomized controlled trial undertaken, 30 obese patients (BMI>30 kg/m2) undergoing laparoscopic bariatric surgery under general anaesthesia were recruited. Patients were randomized to receive desflurane or TIVA using a target-controlled infusion for maintenance of anaesthesia. As a marker of inflammation, pre-and post-surgery IL-6 levels were compared. Results: After surgery, IL-6 levels increased significantly in both groups. The rise in IL-6 was less with TIVA than with desflurane; however, it did not reach significance. IL-6 rise post-surgery correlated positively with the complexity of procedure and duration of surgery and anaesthesia, rather than anaesthetic technique. Both groups did not differ in terms of intra-operative hemodynamic and respiratory variables, time to awakening, postoperative pulmonary complications, and duration of hospital stay. The incidence of nausea was significantly higher with desflurane than with TIVA. Conclusion: Inflammatory response did not differ as a function of anaesthetic technique when propofol and desflurane were compared. Also, patient and surgical variables dictated post-operative inflammation more than the anaesthetic factors. Further, larger sample size is needed to confirm or refute these findings.

Keywords: bariatric, biomarkers, inflammation, laparoscopy

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