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BACKGROUND: Passive movements of head and neck are sometimes unavoidable during surgery under general anesthesia due to patient positioning according to the needs of the surgery or transmitted movements from surgical manipulations. AIMS: This prospective crossover randomized study evaluates the effects of passive movements of the head and neck on the performance of i-gel® supraglottic airway device in spontaneously breathing patients under general anesthesia. MATERIALS AND METHODS: Sixty spontaneously breathing patients on pressure support ventilation with positive end-expiratory pressure (PEEP) under general anesthesia were randomized to seven sequences of passive head-and-neck movements with i-gel® in situ. After steady state of general anesthesia was achieved and maintenance with sevoflurane in N2O and O2 was reached, the passive head-and-neck movements were done. Peak airway pressure, exhaled minute volume, end-tidal carbon dioxide (ETCO2), oxygen saturation, audible leak of airway gases, and visible outward displacement of the i-gel® were recorded in the neutral position and with each passive head-and-neck movement. Paired continuous data were analyzed by Friedman rank sum test with paired Wilcoxon signed-rank test. Paired nominal data were analyzed by Cochran's Q test with pair-wise McNemar test. RESULTS: Extension, right or left lateral flexion, and right or left rotation of the head and neck resulted in significant reduction in the exhaled minute ventilation, rise in ETCO2, and leak of airway gases compared to the neutral position (P < 0.05). Flexion movement did not cause significant changes in the exhaled minute ventilation, rise in ETCO2, and audible leak of airway gases as compared to the neutral position. CONCLUSIONS: Ventilatory performance of the i-gel® deteriorates upon extension, right or left lateral flexion, and right or left rotation of the head and neck in spontaneously breathing patients under general anesthesia on pressure support ventilation with PEEP.
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BACKGROUND: Abundant published literature exists addressing the issues of outpatient waiting lists before surgery. However, there is no published literature on inpatient waiting time before elective surgical procedures. OBJECTIVES: This study aims to measure the inpatient waiting time, identify the factors that affect the inpatient waiting time, and recommend the ways of reducing the waiting time of inpatients before elective surgical procedures, at a state government teaching hospital in India. METHODS: Descriptive research methods and quality control tools were used for this prospective observational study. Descriptive statistics, Shapiro-Wilk test of normality, Wilcoxon-Mann-Whitney Test, and Kruskal-Wallis test were used. Pareto charts were used to highlight the most important modifiable factors among the set of factors causing increased waiting time. We also applied the M/M/c model (Erlang - A model) of queue theory to analyze the traffic intensity and system congestion. RESULTS: The median waiting time of inpatients before elective surgery was 12 days (interquartile range = 11.5 days). The waiting time was influenced significantly (P < 0.05) by the patient's age, physical status, and the financial status. The surgical specialty, blood product booking and procurement, cross-specialty consultation before surgery, and Intensive Care Unit booking were the other important factors. CONCLUSION: 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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Procedimientos Quirúrgicos Electivos , Pacientes Internos/estadística & datos numéricos , Listas de Espera , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Hospitales de Enseñanza , Humanos , India , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
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.
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BACKGROUND: Nasogastric tube (NGT) insertion is indicated almost routinely in patients undergoing abdominal surgery to decompress the stomach intraoperatively and postoperatively, and to allow postoperative tube feeding. NGTs are made of nonreinforced polymer plastic materials and are prone to kinking and coiling during insertion. This often poses difficulty in blind NGT placement or placement assisted by variously described techniques. We hypothesized that esophageal guidewire-assisted NGT insertion with manual forward laryngeal displacement can significantly improve the first-attempt success rate over the technique of head flexion and lateral neck pressure during its insertion in anesthetized and tracheally intubated patients. METHODS: Four hundred eighty adult patients presenting for abdominal surgery under general anesthesia with neuromuscular relaxation were randomized to an experimental technique of esophageal guidewire with manual forward displacement of the larynx (group 1) or a control technique of head flexion and lateral neck pressure (group 2) for insertion of the NGT. The success rates (and failure rate) of the first and second attempts (and overall) were assessed along with the incidence of coiling and kinking of the NGT, procedure-related nasal bleeding and pharyngeal bleeding, and the incidence of moderate and life-threatening complications. RESULTS: The first-attempt success rate was 99.2% in group 1 compared with 56.7% in group 2 (P < 0.001). Thus, the first-attempt failure rate was 0.8% in group 1 compared with 43.3% in group 2 (P < 0.001, absolute risk reduction of first-attempt failure rate = 42.5%, 95% confidence interval [CI] = 36.0%-49.9%; numbers needed to treat = 2, 95% CI = 2-3; relative risk reduction of first-attempt failure rate = 98.1%, 95% CI = 92.3%-99.5%). The median time required to insert the NGT was significantly shorter in group 1 (55 vs 60 seconds); P < 0.001, 95% CI for the difference in means = 3.2 to 6.8 seconds. The incidences of kinking/coiling, bleeding, and moderate injuries were significantly lower in group 1. CONCLUSIONS: 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.
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Anestesia General , Esófago/anatomía & histología , Intubación Gastrointestinal/instrumentación , Intubación Intratraqueal , Abdomen/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Diseño de Equipo , Femenino , Humanos , India , Intubación Gastrointestinal/efectos adversos , Intubación Gastrointestinal/métodos , Laringe/anatomía & histología , Masculino , Persona de Mediana Edad , Posicionamiento del Paciente , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Post-operative cognitive dysfunction is the subtle cerebral complication temporally seen following surgery. The aim of this study was to compare the influence of either general anesthesia (GA) or epidural anesthesia (EA) on the early post-operative neurocognitive outcome in elderly (>59 years) subjects undergoing hip and knee surgery. METHODS: A total of 60 patients were recruited in a prospective, randomized, parallel-group study, comparable by age and sex. They were enrolled and randomized to receive either EA (n = 30) or GA (n = 30). All of them were screened using the Mini Mental State Examination (MMSE), with components of the Kolkata Cognitive Screening Battery. The operated patients were re-evaluated 1 week after surgery using the same scale. The data collected were analyzed to assess statistical significance. RESULTS: We observed no statistical difference in cognitive behavior in either group pre-operatively, which were comparable with respect to age, sex and type of surgery. Grossly, a significant difference was seen between the two groups with respect to the perioperative changes in verbal fluency for categories and MMSE scores. However, these differences were not significant after the application of the Bonferroni correction for multiple analyses, except the significant differences observed only in the MMSE scores. CONCLUSIONS: We observed a difference in cognitive outcome with GA compared with EA. Certain aspects of the cognition were affected to a greater extent in this group of patients undergoing hip and knee surgery.
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BACKGROUND: Propofol (2,6-di-isopropylphenol) used for the induction of anesthesia often causes mild to severe pain or discomfort on injection, for which various methods have been tried, but with conflicting results. OBJECTIVE: The present study involved pretreatment with lignocaine, fentanyl and placebo for prevention of pain on propofol injection to determine the difference in efficacy of fentanyl 100 µg compared with lignocaine 40 mg. MATERIALS AND METHODS: Sixty-three participants of either sex, between 18 and 60 years of age, belonging to ASA physical status 1 and 2, undergoing elective surgery under general anesthesia, were randomized into three equal groups of 21 participants. They received, intravenously, either lignocaine (20 mg/mL) or fentanyl (50 µg/mL) or placebo (normal saline 2 mL) pretreatment before the propofol injection. RESULTS: The three groups were comparable with respect to age, height, weight, sex and ASA physical status. The incidences of pain on pretreatment drug injection was higher in the fentanyl group (33.3%) compared with lignocaine and normal saline (P<0.05). The lowest incidence of pain on propofol injection was observed in the lignocaine pretreatment group (14.3%) compared with fentanyl (42.9%) and normal saline (71.4%) (P<0.05). There was no significant difference in adverse skin reaction within groups. In the normal saline pretreatment group, 38.1% of the participants experienced severe pain, compared with 9.5% in the fentanyl (P<0.05) group; none with lignocaine. The number needed to treat was 2 in the lignocaine pretreatment group compared with 4 in the fentanyl pretreatment group. CONCLUSION: Compared with fentanyl, lignocaine pretreatment was more effective in preventing pain on propofol injection.