StatisticianIrum Abid

Editorial Board:Arshad Taqi (Pakistan)Dario Galante (Italy)Fazal Hameed (Pakistan)Gauhar Afshan (Pakistan)Joseph D. Tobias (USA)Khalid Bashir (Pakistan)Koji Sumikawa (Japan)Mohamad Said Ahmad Maani Takrouri (Saudi Arabia)Pramila Bajaj (India)Rana Altaf Ahmad (Pakistan)Rashed A. Hasan (USA)Saeid Safari (Iran)Shahab Naqvi (Pakistan)S. K. Malhotra (India)Waqas Ahmed Qazi (Pakistan)

Associate Editors:Zahid Akhtar RaoAssociate Prof. of Anaesthesia, Bahria Univ. Medical & DentalCollege, Karachi (Pakistan)zahidrao57@gmail.com

Fares ChedidConsultant NeonatologistTawam Hospital, Al Ain, Abu Dhabi (UAE)fareschedid@hotmail.com

Assistant Editors:Pranav Bansal (India)drpranav_bansal@yahoo.com

Muhammad Faisal Khan (KSA)mfkdr.icu@gmail.com

Amer Majeed (UK)amer.majeed@gmail.com

Logan Danielson (USA)logandanielson@gmail.com

Patron:Brig. M. Salim. SI(M)Professor of Anesthesiology President STSPbrigsaleem@dsl.net.pk

Editor-in-Chief:Tariq Hayat KhanConsultant Anesthesiologist & Pain SpecialistVice President STSPapicare@yahoo.com

Editors:Samina IsmailAssociate Prof. of Anaesthesia, AKUH Karachi.samina.ismail@yahoo.com

Said AbuhasnaChairman, Dept. of Critical Care Medicine, Chief Intensive Care Unit, Tawam Hospital, Al Ain, Abu Dhabi (UAE)sabuhasna@tawamhospital.ae

ANAESTHESIA, PAIN& INTENSIVE CARE

An International Journal of Anesthesiology, Pain Management, Intensive Care & Resuscitation

Vol. 17 No. 1 January - April 2013

Published by: Dr. Tariq Hayat Khan

‘Anaesthesia, Pain & Intensive Care’ is indexed by PakMediNet, Medlip. Index Medicus (EMR), EBSCO, Index Copernicus, Embase, EMCare, UDL (Malaysia), DOAJ, Web Mèdica Acreditada Quality Program (WMA), WMA Google Search.

Listed with: National Library of Medicine Catalogue NLM ID: 101313795 [Serial]; HINARI portal.

Registered by Pakistan Medical & Dental Council (PM&DC). Recognized by Higher Education Commission (HEC)Permission granted by District Magistrate Islamabad for publication.

General Information: The journal is published thrice a year in the months of April, August and December. Please direct inquiries regarding subscriptions, single copies and back issues, changes of addresses, and other correspondence to the Publications Office. Advertising inquiries should also be sent to the same address. See us at FACE BOOK, Twitter, Linked in and Medpedia All articles represent the opinions of the authors and do not reflect official policy of the journal. All rights are reserved to the publisher. No part of the journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, regarding, or via any retrieval system, without written permission from the publisher.

Subscription Rates: The rates for a one-year subscription of the Journal are Pak Rupees 1000 for subscribers in Pakistan, Pak Rupees 2000 for institutions in Pakistan, Pak Rupees 2000 for subscribers from SAARC countries and Pak Rupees 4000 from elsewhere.

Regional Office (Pakistan): Dept of Anaesthesia and Pain Management, AKUH, Karachi.Ph: +92-21-34864631/4331

Regional Office (UAE): Dept of Anaesthesia and Critical Care, Tawam Hospital, P.O. Box 152858, Al-Ain, Abu Dhabi (UAE).

Head Office: ‘APICARE’60-A, Nazim-ud-Din Road, F-8/4, Islamabad (Pakistan)E-mail: apicare@yahoo.com, apicjournal@gmail.comwww.apicareonline.com Ph: +92-321-5149709

Cover Picture: “Siesta” 15th November 2010By: Dr Amer Majeed

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 Vol. 17 No. 1

coNTeNTs

eDIToRIAL VIeWs

Transfusion, under-transfusion and 1over-transfusionTariq Hayat Khan

can you stop this shivering doctor? 4Arshad Taqi

Postoperative nausea and 6vomiting (PoNV): A cause for concernKhalil Ullah Shibli

sPecIAL ARTIcLe

Termination of ventilatory support of 10a patient under compulsion, who is not yet brain deadS.K.Malhotra

oRIGINAL ARTIcLes

sedation with propofol during combined 14spinal epidural anesthesia: comparison of dose requirement of propofol with and without BIs monitoring R. K. Verma, Anil K Paswan, Shashi Prakash, Surender K. Gupta, P.K. Gupta

Does intra-cuff alkalinized lidocaine 18prevent tracheal tube induced emergence phenomena in children?Mona S. Ahmady, Sayed Sadek, Roshdi R. Al-metwalli

Thoracic epidural for post-thoracotomy 22and thoracomyoplasty pain: a comparative study of three concentrations of fentanyl with plain ropivacaineAjay Kr Chaudhary, Dinesh Singh, Jai Shri Bogra, Sulekha Saxena, Girish Chandra, Shashi Bhusan, Prithvi Kr Singh

‘Maximum surgical Blood order 28schedule’ in a newly set-up tertiary care hospitalR. Thabah, L. T. Sailo, J. Bardoloi, M. Lanleila, N. M. Lyngdoh, M. Yunus, P. Bhattacharyya

comparison of intravenous butorphanol, 33ondansetron and tramadol for control of shivering during regional anesthesia: A prospective, randomized double-blind studyJoshi Smita Suresh, Adit Arora, Arun George, Shidhaye Ramchandra Vinayak,

A cross-sectional study of knowledge 40and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (sri Lanka)M.V.G. Pinto, R Varun, W. M. M. P. B. Wanasinghe, T. M. K. Jayasinghearachchi, H. M. T. A Herath, P. V. R. Kumarasiri,

Use of a portable oxygen concentrator 45and its effect on the overall functionality of a remote field medical unit at 3650 meters elevationRehan Masroor, Amjad Iqbal, Khalid Buland, Waqas Ahmad Kazi

A retrospective seven years audit of 51mode of deliveries in a tertiary care university hospital of TurkeyBerrin Gunaydin, Kadir Kaya

A prospective, randomized, double-blind, 55comparative study of the efficacy of intravenous ondansetron and palonosetron for prevention of postoperative nausea and vomitingBijaya Kumar Shadangi, Jitendra Agrawal, Rabindra Pandey, Arvind Kumar, Sanjay Jain, Rakhi Mittal, H K Chorasia

Diurnal variation of extremely low 59frequency electromagnetic field in an empty operating roomJae Wook Jung, Yong Han Kim, Gwang Cheol Go, Jae Hong Park, Sang Yoon Jeon, Sang Eun Lee, Sira Bang, Ki Hwa Lee, Ki Hoon Kim

sHoRT coMMUNIcATIoNThe prevalence of obstructive sleep 63 apnea characteristics in patients with Barrett’s esophagusMedhat Hannallah, Yonette Exeter, Maggie Gillespie, Jason Hoefling

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 Vol. 17 No. 1

coNTeNTs

ReVIeW ARTIcLe

Prehospital trauma care services in 65developing countriesLakesh Kumar Anand, Manpreet Singh, Dheeraj Kapoor

cAse RePoRTssuccessful intubation with air-Q in 71Pierre Robin syndromeTariq Hayat Khan, Amna Ghayas, Ayesha, Samreen Khushbakht, Adeel Ahmed, Naeem Khan

Anesthetic considerations in Morquio 75syndrome: A case reportThorat Pravin Shivajirao, Nageshkumar P Wasmatkar, Pratibha Govindrao Gore, J. N. Lakhe, Shidhaye Ramchandra Vinayak,

challenges during prolonged mechanical 79ventilation of a morbidly obese lady with hypothyroidism and sleep apnea syndromeSaurabh Kumar Das, D. K. Singh, Sujali Choupoo, Ghanshyam Yadav,

Dexmedetomidine and the perioperative 83care in Riley-Day syndrome: a case report and literature reviewMatthew DiGiusto, David Martin, Joseph D. Tobias

successful treatment of severe Legionella 88pneumonia and acute kidney injury with polymyxin B-immobilized fiber column direct hemoperfusionYasunari Matsuki, Yuka Matsuki, Yoshikazu Yasuda, Maki Mizogami, Ko Takakura, Kenji Shigemi

Accidental asphyxiation by an Arabic 91headscarfSaid D. Abuhasna, Mustafa Abu Ebaid, Eman D.M. Qadoom, Masood Ur Rahman

Failed ventilation with LMA Proseal® in 94a patient with sleep apnea syndromeAnju Ghai, Sarla Hooda, Raman Wadhera, , Nandita Kad, Nidhi Garg

Airway management in a patient with a 97large mass in scapular region: A case reportHaidar Abbas, Zia Arshad, Sulekha Saxena, Jai Shree Bogra

LeTTeR To eDIToR

Valsalva maneuver aids blind central 100venous catheterizationSukhen Samanta and Rudrashish Haldar

Accidental intra arterial injection of 101diclofenac sodium and consequences: report of two casesSukhen Samanta and Rudrashish Haldar

TReNDs & TecHNoLoGy 103cLINIQUIZ

Acute respiratory distress syndrome 104Pranav Bansal, Gaurav Jain, Meenu Agarwal, Karamveer Singh

cALeNDAR oF eVeNTs 106cLINIPIcs

optimising the length of i-gel 108Tariq Hayat Khan, Amna Ghayas, Ayesha, Shiraz Naeem, Naeem Khan

‘My Most Memorable Patient’® 54Nabil Estemalik

‘My Most Unforgettable experience’® 107Me and my fibromyalgiaValerie Lumley

The ‘APICARE’ agrees to accept manuscripts prepared in ac-cordance with the ‘Uniform Requirement for Submission of Manuscripts Submitted to Biomedical Journals’ published in the British Medical Joumal 1991 ;302:334N1, All material submitted for publication should be sent exclusively to the ‘APICARE’.

ETHICAL CONSIDERATIONS: If tables, illustrations or photographs, which have been already published, are included, a letter of permission for their re-publication should be obtained from author(s) as well as the editor of the journal where it was previously printed. Permission to reproduce photographs of pa-tients whose identity is not disguised should be sent with the manuscript otherwise the eyes will be blackened out.

MATERIAL FOR PUBLICATION: The material submitted for publication may be in the form of an Original Research, a Re-view Article, a Case Report, Recent Advances, New Techniques, Debates, Book Review/CDs on Clinical/Medical Education, or a Letter to the Editor. Original articles should normally report original research of relevance to clinical anaesthesiology, pain management, intensive care or resuscitation, and may appear ei-ther as a paper or as short communications. The paper should be of about 2000 words, with no more than six tables or illus-trations, short communications should be of about 600 words, with one table or illustration and no more than five references. Clinical case reports and brief or negative research findings may appear in this section. Review article should consist of structured overview of some relatively narrow topic providing background, recent development with reference to original literature.

Letters should normally not exceed 400 words, have no more than 10 references, and be signed by all of the authors. An article based on dissertation submitted as part of the requirement for a fellowship of the postgraduate degree awarding medical institu-tions can be sent for publication after the Research and Training Monitoring Cell (RTMC) have approved it. Editorials are writ-ten by invitation.

Each manuscript should include a title page (containing e-mail address, fax and phone numbers of the corresponding author), abstract, text, acknowledgments, references, tables, and legends.

Each component should begin on a new page, in the following sequence: title page: abstract and keywords: text; acknowledg-ments; references; tables (each table, complete with title and footnotes, on a separate page); and legends for illustrations.

The manuscript should be typed in double spacing on 8 ½″ x 11″ (21.5cm x 28.0cm) white bond paper with one-inch (2.5cm) mar-gin on both sides. It should not exceed 20 pages, excluding tables and references. There should be no more than 40 references in an Original Article, and no more than 100 in a Review Article.

TABLES AND ILLUSTRATIONS: Tables and illustrations should be submitted separately, and legends to illustrations should be typed on a separate sheet. Each table should have a title and be typed in double space without horizontal and verti-cal lines on an 8 ½″ x 11″ (21.5 x 28.0 cm) paper. Tables should be numbered consecutively with Roman numerals in the order they are mentioned in the text. Page number should be in the upper right corner, if abbreviations are used, they should be explained in footnotes. When graphs, scatter grams, or histograms are sub-mitted, the numerical data on which they are based should be supplied.

S.I. UNITS: System Intemational (Sl) Unit measurements should be used. All drugs must be mentioned in generic form. The com-mercial name may, however, be mentioned with in brackets.

FIGURES AND PHOTOGRAPHS: Should be sent only when data cannot be expressed in any other form. These must be unmounted, glossy prints in sharp focus, 5″ x 7″, (12.7 x 17.3

cm) in size. These may be in black and white or in colour. Nega-tives, transparencies, and X-ray films should not be submitted. The number of the figure, the name of the author(s) should be printed on the back of each figure/photograph, and must be cit-ed in the text in consecutive order. Legends must be typed on a separate sheet of paper. Legends for photographs should indicate the magnification, internal scale and the method of staining. Pho-tographs in published articles will not be returned.

REFERENCES: Should be numbered in the order in which they are cited in the text. At the end of the article, the full list of references should give the names and initials of all authors (unless there are more than six when only the first six should be given followed by et al). The authors’ names are followed by the title of the article; the title of the journal abbreviated according to the style of the Index Medicus. e.g.: Hall, RR. The heading of tissues by CO2 laser. Br J. Surg 1971; 58:222-225. Reference to books should give the names of editors, place of publication, publisher, and year.

PEER REVIEW: Every paper will be reviewed by a member of the editorial committee, and one or more external reviewers. Statistical analysis wail be examined by a statistician.

ABSTRACT: Abstracts of onginal article should be prepared with a structured format. The elements addressed could include objectives, design, setting, patients or other participants, inter-ventions, and outcome measures, the results, and conclusions. Please label each section clearly with the appropriate subheading. Review article, Case report and other require a short, unstruc-tured abstract Commentaries do not require abstract. A list of key words should be given consisting of MeSH terms.

INTRODUCTION: This should include the purpose of the ar-ticle. The rationale for the study or observation should be sum-marised; only strictly pertinent references should be cited; the subject should not be extensively reviewed Data or conclusions from the work being reported should not be presented.

METHODOLOGY: The selection of the observational or ex-perimental subjects (patients or experimental animals, including controls) should be described clearly in the methods and the ap-paratus used should be identified (with the manufacturers name and address in parentheses), and procedures described in suffi-cient detail to allow other workers to reproduce the results Ref-erences to established methods should be given, including statis-tical methods; references and brief descriptions for methods that have been published but are not wall known should be provided; new or substantially modified methods should be described, giv-ing reasons for using them, and evaluating their limitations. All drugs and chemicals used should be identified precisely, includ-ing generic name(s), dose(s), and route(s) of administration.

RESULTS: These should be presented in a logical sequence in the text, tables, and illustrations. All the data in the tables or illustrations should not be repeated in the text; only important observations should be emphasized or summarised.

DISCUSSION: The authors comments on the results, sup-ported with contemporary references, including arguments and analysis of identical work done by other workers. A summary is not required. Brief acknowledgment may be made at the end.

ONLINE SUBMISSION: The manuscripts maybe submitted online via our website www.apicareonline.com or sent as e-mail attachments to the head office or one of the regional offices. Pictures must be sent separately as JPEG or in TIFF format. Submission of scanned copies of the tables, diagrams, Graphs, and Pictures is not acceptable. Model submission letter maybe downloaded from the website, duly filled in, signed by all of the authors and must be submitted along with the manuscript.

Instructions for authors

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 1

eDIToRIAL VIeW

Transfusion, under-transfusion and over-transfusionTariq Hayat Khan, MBBS, MCPS, FCPSConsultant anesthesiologist, Department of anesthesiology, KRL General Hospital, G-9/1, Islamabad (Pakistan)

Correspondence: Dr. Tariq Hayat Khan, FCPS, Consultant anesthesiologist, H. No. 163, Street 53, G-10/3, Islamabad (Pakistan); Cell: +92 321 5149709; E-mail: tariqhayatkhan@hotmail.com

SUMMARYThe incidence of transfusion has increased day by day due to many factors, including increasing population, enhanced expertise and facilities to operate once inoperable conditions and the willingness of the public to pay high cost of advanced surgical procedures. Trauma services have been well-organized now and victims may have massive transfusion. Many authors have pointed out the need of protocols and guidelines to be followed to avoid transfusion associated risks and complications. Under-transfusion has been preferred to over-transfusion and a need to have a ‘Maximum Surgical Blood Order Schedule’ has been stressed.

Key words: Blood transfusion; Massive transfusion; Over-transfusion; Under-transfusion; Transfusion-related acute lung injury; TRALI; Transfusion-associated circulatory overload; TACO

Citation: Khan TH. Transfusion, under-transfusion and over-transfusion. Anaesth Pain & Intensive Care 2013;17(1):1-3

Blood transfusion is in practice for many decades, but it has been associated with some controversies since its start. Before the era of the advent of current cross-matching techniques and before the advanced screening techniques for bacterial and viral contamination, it led to immeasurable morbidity and mortality. Still, the number of transfusions has steadily increased over the last three or four decades throughout the world, a 128% growth rate between 1997 and 2009.1 The progress in cardiothoracic, neurosurgery and trauma surgery plus establishment of blood banks and transfusion services has played a major positive role in this increase. In the United States, more than 15 million units of RBCs are transfused annually.2 The Agency for Healthcare Research and Quality (AHRQ) reports that blood transfusion is the most frequently performed procedure for inpatients.1 Medical research is continuing in search of good and more appropriate protocols and guidelines to regulate transfusion practices, as many researchers have pointed out that the current trend favors inappropriate or unjustified transfusion.3 The questions, ‘At what point you would start transfusion’ and ‘how much’ must be asked before ordering transfusion. An increased morbidity and mortality has been observed in patients who are transfused at a higher rather than a lower hemoglobin (Hb) threshold.4-6 Blood may not be needed in every

patient with asymptomatic anemia and it may be pharmacologically treatable with folate, vitamin B12, or iron, in which case transfusion can be avoided. In our practice we have noted a persistent Hb level below 10 gm in pregnant ladies of our population. Levels between 7-9 are the most common finding, and blood needed to be transfused very rarely during cesarean sections. This transfusion avoidance strategy can be applied to inpatients as well. A patient who was leading an active life and was completely asymptomatic at a Hb level of 7 gm, will hopefully tolerate a blood loss of 400-500 ml during her cesarean section. Many international societies and associations have formulated clinical practice guideline for transfusion, recommending a restrictive transfusion strategy, i.e., considering transfusion only at a hemoglobin level of less than 7 to 8 g/dl in hospitalized, stable patients.7 The Joint Commission has proposed National Patient Safety Goal 16.01.01 “to minimize the overuse of tests, treatments, and procedures to reduce the risk of patient harm.”8

Although there is a thin line between massive transfusion and over-transfusion, for all practical purposes, the risks associated with blood transfusion are multiplied with both of these. Massive transfusion is usually defined as the use of ten or more bags of blood in a single patient; whereas, over-transfusion can be described as

2 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

transfusion issues

the practice of transfusing blood or blood products in excess of the actual and genuine needs of the patient. MT may not always be justified in most of the critical situations, when reasonable estimate of blood loss is difficult or impracticable. The anesthesiologists and the surgeons usually depend upon visual estimates for ordering blood and have a tendency to over-transfuse in emergency related confusion.Over-transfusion still continues on an international level. Although the risk of transfusion-transmitted diseases has greatly reduced, with the following current rates: HIV, 1 transmission in every 2 million units; hepatitis C virus (HCV), 1 in every 2 million units and hepatitis B virus (HBV), 1 in every 200,000 units transfused, bacterial contamination of platelets continues to carry a high risk at 1 in 2,000 units transfused.9,10 The problem is not confined to transmission of disease only, transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO), both noninfectious conditions, are the two leading causes of fatalities associated with transfusion.

The risk of all these increases with every bag of blood transfused. We need to ensure that the indication of blood transfusion for each patient is evidence-based and consistent with current guidelines.The anesthesiologists are well aware that stored blood cells undergo multiple biochemical, functional, and structural changes, a condition referred to as the RBC storage lesion, and that 2,3-diphosphoglycerate (2,3-DPG) decreases in these, shifting the oxyhemoglobin dissociation curve to the left, making these less efficient in delivering oxygen to the tissues. Stored cells have insufficient nitric oxide (NO) bioavailability, which also results in vasoconstriction and decreased oxygen delivery.11 Transfusing RBCs, stored for more than 2 weeks, have been associated with a statistically significant risk of postoperative complications, including increased mortality, prolonged ventilator support, increased renal failure, and sepsis.12

It is reasonable to assume that the incidence of transfusion errors will be increased with massive transfusion or over-transfusion. Most of these are caused by patient caregivers outside the laboratory and a lesser number by the hospital transfusion service. Surprisingly, phlebotomy has been found to account for 13% of all transfusion-associated errors.13 A study reviewing 4,000 transfusion audits from the College of American Pathologists Q-Probe data revealed that in 25% of transfusions, the transfusionist failed to confirm patient identification.14 Missed identification may lead to mistransfusion. Mistransfusion, the transfusion of a unit of blood to the wrong patient, is the leading cause of mortality associated with transfusion. Using

data from the New York State Department of Health errors database, Linden and colleagues reported that the risk of mistransfusion was one in every 12,000 procedures.15 ABO-incompatible mistransfusions occur at a rate of 1 in every 33,000 procedures, with 1 in every 600,000 resulting in death.15 The Joint Commission has had patient identification as the number one National Patient Safety Goal (NPSG) for many years. In the 2012 National Patient Safety Goals, TJC has added NPSG 01.03.01 to eliminate transfusion errors related to patient misidentification.16

Under-transfusion may be defined as transfusing blood in a volume less than that estimated to be required for a particular patient. Careful estimation of the intraoperative blood loss will guide us towards projected Hb after all that hemodilution by crystalloids and/or colloids. Blood loss may be justified to be fully compensated in neonatal and pediatric surgery, many anesthesiologists will rely upon their visual assessment and transfuse if absolutely essential. Postoperative Hb estimate may be a better guide to replace blood loss. Under-transfusion has many advantages; less risk of spread of blood related infections, less risk of transfusion errors, avoidance of TRALI and TACO, and less financial burden on the patient. It will be tolerated by many patients except patients of cardiovascular disease. Anemia is the worst enemy of cardiac patients due to associated circulatory overload. A study about perioperative cardiac morbidity in 1990 stated that of the 25 million patients undergoing noncardiac surgery each year in the United States, approximately one third, or 8 million are at risk for cardiac morbidity or mortality.17 Many of these patients will also be anemic, whether due to acute blood loss (surgery or trauma) or chronic conditions such as renal failure or cancer. Attempts to limit the volume of allogeneic blood transfused have focused on tolerance of lower hemoglobin levels, but such a practice may increase risk in these patients. No doubt, in the perioperative period, the most commonly cited risk factors for adverse cardiac outcomes are gender, age, urgency of operation, and the presence of existing congestive heart failure, diabetes or significant cerebral vascular occlusive disease.18 Patients without coronary artery disease, have a tremendous ability to compensate for decreases in coronary arterial oxygen content; patients with coronary artery disease have a limited ability to compensate for or to tolerate uncompensated decreases in myocardial oxygen delivery, and there is a narrow window of Hb or hematocrit values at which these patients do the best. Hematocrit values below 28% or above 35% appear to be associated with increasing risk of morbidity and mortality whether in chronic or

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 3

editorial view

acute anemia.

Jehovah’s Witnesses have provided great opportunity to the researchers to study the effects of anemia and the tolerance of blood loss during trauma or surgery. In a study of 125 such patients undergoing surgery, both intraoperative blood loss and perioperative Hb levels were found to be independent predictors of postoperative mortality (rising from 6% at Hb levels of >8 g/dl to 61% at Hb levels of <6 g/dl).19 Another study provided contradictory evidence, citing children of Jehovah’s Witnesses with HB levels of 3 g/dl tolerating bypass without difficulty18. A final study of the association between anemia and mortality in Jehovah’s Witnesses reported that blood loss of >500 ml during surgery was a more important risk factor than was preoperative Hb.20

There is little clinical evidence that permits prediction

of the critical Hb or hematocrit at which ischemia will develop in any given patient.To control the over-judicious crossmatch orders, and over-transfusion, strict blood utilization criteria need to be enforced in every hospital. The common practice of ordering two units of blood has to be changed in favour of ordering a single unit at a time, and type and crossmatch orders need to be abandoned in favor of type and screen. Some departments insist that crossmatch orders must mention documented clinical. A periodic review of the existing protocols and the practices is recommended for maximum optimization. The protocols may differ from time to time within a single institution or from institution to institution. The study by Thabah R et al21 in this issue of the journal emphasizes the need of proper assessments of the requirement of blood and blood products in every institution. Protocols need to be made and adhered to.

1. Health Cost and Utilization Project. Statistics on Hospital-based Care in the United States, 2009. Washington, DC: Agency for Healthcare Research and Quality; 2011. [Access Online]

2. Office of the Assistant Secretary of Health. The 2009 National Blood Collection and Utilization Survey Report. Washington, DC: Department of Health and Human Services; 2011. [Access Online]

3. Rothschild JM, McGurk S, Honour M, et al. Assessment of education and computerized decision support interventions for improving transfusion practice. Transfusion. 2007;47(2):228-239. [Medline]

4. Hébert PC, Well G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340(6):409-417. [Medline] [Free Full Text]

5. De Oliveira GS Jr, Schink JC, Buoy C, et al. The association between allogeneic perioperative blood transfusion on tumour recurrence and survival in patients with advanced ovarian cancer. Transfus Med. 2012;22(2):97-103. [Medline]

6. Paone G, Brewer R, Theurer PF, et al. Preoperative predicted risk does not fully explain the association between red blood cell transfusion and mortality in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2012;143(1):178-185. [Medline]

7. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB [published ahead of print March

26, 2012]. Ann Intern Med. http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-201206190-00429.long. Accessed July 2, 2012.

8. The Joint Commission. Critical Access Hospital Accreditation Program. Proposed national patient safety goal 16.01.01. http://www.jointcommission.org/assets/1/6/CAH_NPSG_Overuse_Rpt_2011-11-14.pdf. Accessed July 2, 2012.

9. National Heart Lung and Blood Institute. What are the risks of a blood transfusion?http://www.nhlbi.nih.gov/health/health-topics/topics/bt/risks.html. Published January 30, 2012. Accessed July 2, 2012.

10. Centers for Disease Control and Prevention. Blood safety. http://www.cdc.gov/bloodsafety/bbp/diseases_organisms.html. Updated May 8, 2012. Accessed July 2, 2012.

11. Roback JD. Vascular effects of the red blood cell storage lesion. Hematology Am Soc Hematol Educ Program 2011;2001:475-479. [Medline] [Free Full Text]

12. Koch CG, Li L, Sessler DI, et al. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med. 2008;358(12):1229-1239. [Medline] [Free Full Text]

13. Linden JV, Wagner K, Voytovich A, Sheehan J. Transfusion errors in New York State: an analysis of 10 years’ experience. Transfusion. 2000;40(10):1207-1213. [Medline]

14. Novis DA, Miller KA, Howanitz PJ, et al. Audit of transfusion procedures in 660 hospitals. A College of American Pathologists Q-Probes

study of patient identification and vital sign monitoring frequencies in 16,494 transfusions. Arch Pathol Lab Med. 2003;127(5):541-548. [Medline] [Free Full Text]

15. Linden JV, Paul B, Dressler K. A report of 104 transfusion errors in New York State. Transfusion. 1992;32(7):601-606. [Medline]

16. The Joint Commission. Hospital Accreditation Program. National patient safety goals effective January 1, 2012. NPSG 01.03.01. http://www.jointcommission.org/assets/1/6/NPSG_Chapter_Jan2012_HAP.pdf. Accessed July 2, 2012.

17. Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990;72(1):153-84. [Medline]

18. Cosgrove DM, Loop FD, Lytle BW, Baillot R , Gill CC, Golding LA et al. Primary myocardial revascularization. Trends in surgical mortality. J Thorac Cardiovasc Surg 1984;88(5 Pt 1):673-84. [Medline]

19. Carson JL, Poses RM, Spence RK, Bonavita G. Severity of anaemia and operative mortality and morbidity. Lancet 1988;1(8588):727-9. [Medline]

20. Spence RK, Carson JA, Poses R, McCoy S, Pello M, Alexander J, et al. Elective surgery without transfusion: influence of preoperative hemoglobin level and blood loss on mortality. Am J Surg 1990;159(3):320-4. [Medline]

21. Thabah R, Sailo LT, Bardoloi J, Lanleila M, Lyngdoh NM, Yunus M, Bhattacharyya P. ‘Maximum Surgical Blood Order Schedule’ in a newly set-up tertiary care hospital. Anaesth Pain & Intensive Care 2013;17(1):28-32

REFERENCES

4 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

eDIToRIAL VIeW

can you stop this shivering, doctor?Arshad Taqi**Consultant anesthesiologist, Kaul Associates, Hameed Latif Hospital, Lahore (Pakistan)

Correspondence: Dr. Arshad Taqi, Consultant anesthesiologist, Kaul Associates, Hameed Latif Hospital, Lahore (Pakistan); E-mail: arshadtaqi@gmail.com

SUMMARYPostoperative shivering and feeling of cold associated with it is rated as worse than pain by some patients. It has been a problem not only after general anesthesia, but also during and after spinal anesthesia. This editorial com-pliments an original article in this issue of ‘Anesthesia, Pain & Intensive Care’ on comparison of three different drugs for the treatment of postoperative shivering, and draws attention towards pathogenesis of shivering and its control. Shivering is not a point in time event and its cessation with pharmacological intervention does not guarantee against its recurrence.

Key words: Postoperative shivering; Spinal anesthesia; Tramadol; Butorphanol; Ondanstron

Citation: Taqi A. Can you stop this shivering, doctor? Anaesth Pain & Intensive Care 2013;17(1):4-5

Shivering evolved as a protective response against hypothermia in mammals. This blessing may turn out to be a cause for distress in a significant number of patients undergoing anesthesia. Postoperative shivering is accompanied by cutaneous vasoconstriction and occurs in response to intraoperative hypothermia in majority of cases. Shivering associated with pain and accompanied by cutaneous vasodilatation is observed in around 15% cases.1 Hypothermia during central neuraxial blocks is thought to be a consequence of absence of sensory input from the lower limbs. Patients rate shivering as highly uncomfortable; feeling of cold associated with shivering is rated as worse than pain by some patients. It increases oxygen consumption, increases intraocular and intracranial pressures, interferes with monitoring and adds to postoperative pain by stretching the wounds2. Postoperative pain on the other hand may facilitate nonthermogenic shivering.3 Eberhart has shown that beside patient’s age and endoprosthetic procedures, core hypothermia is an independent risk factors for postoperative shivering.4 Cutaneous warming improves patient comfort and reduces oxygen consumption but fails to decrease the duration of shivering in patients undergoing both regional and general anesthesia. This highlights the limited role of skin temperature in the control of shivering.5 Rapid and effective control of shivering, therefore, is largely achieved using pharmacological means. A wide range of drugs have been tried with varying results; pethidine remains the most frequently tested drug with a consistent efficacy with an intravenous dose that is not likely to cause significant side effects.6

Monoamine theory of thermoregulation proposed by Feldberg and Meyers in 1963 attributed maintenance of body temperature to a balance between norepinephrine and 5-hydoxytryptamine (5-HT) in preoptic area of anterior hypothalamus. We now know that temperature regulation is not confined to a specific area of the brain, it is rather modulated by an interplay between different areas of the brain and spinal cord and chemical mediation is not confined to norepinephrine and 5-HT, peptides and cholinergic receptors influence the interthreshold range (range of temperatures between onset of shivering and sweating).7 Therapies aimed at control of shivering largely work by targeting these chemical mediators. Tramadol largely works through its effect on alpha-2 receptors; nefopam, is a powerful antishivering agent inhibiting synaptosomal uptake of serotonin (5-HT), norepinephrine and dopamine. NMDA receptors are also involved, which explains the role of ketamine in preventing and treating shivering.8 In this issue of this journal, Suresh et al have compared the efficacy and safety of ondansetron, butorphanol and tramadol for control of shivering in patients undergoing surgery under spinal anesthesia.9 This study highlights the importance of pharmacological interventions in control of shivering. The study is well designed; method of randomisation is described, both subjects and observers were blinded, eliminating the possibility of selection or observer bias; a sample size with the power to detect the difference between interventions was calculated and enough patients were recruited to have 13 or more patients shivering in each group; minimum required to detect a difference with sufficient power. Results of the study, however

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 5

editorial view

are not exactly in line with earlier studies carried out with these agents. One reason could be different doses used. Ondansetrone was used in a dose of 4.0 mg - a dose usually employed for control of nausea and vomiting in clinical practice. Powell et al have shown that ondansetrone 8.0 mg rather than 4.0 mg is effective in preventing postoperative shivering as compared to placebo, lower efficacy of the drug in this study, therefore may not be surprising.10 Butorphanol had a more rapid onset of effect and was effective in the control of shivering in greater number of patients with recurrence of shivering in lower number with tramadol. Both tramadol and butorphanol were significantly superior to ondansetron, no comparison was done between butorphanol and tramadol, which do not look significantly different in their effect, except a more rapid onset of effect with butorphanol at one minute. Authors have conceded that the sample size may be small considering the burden of the problem. This may have contributed to lack of efficacy with ondansetron, a drug that has demonstrated its efficacy in other studies. A limitation of the study is failure to measure the core temperature. Ozer et al have shown that

core temperature decreases while surface temperature increases irrespective of anesthetic technique. With ambient temperature of the operating room ranging between 22° to 28° C there is a possibility that differences in core temperature may have contributed to the frequency of shivering within groups.11 Sedation was more frequent in butorphanol whereas nausea and vomiting were more frequent in tramadol groups, but was the study powered to detect a difference in these outcomes?

Shivering is not a point in time event and its cessation with pharmacological intervention does not guarantee against its recurrence. The authors followed these patients to look for recurrence of shivering that was observed in both Butorphanol and Tramadol but interestingly not in Ondansetron group. Perhaps a larger study would be able to observe the duration of anti shivering effect of ondansetron.

In the end, the authors need to be complemented for highlighting an important area for concern in our practice. Results of this study raise a few questions that can only be answered with further research.

1. Alfonsi P. Postanesthetic shivering; pathophysiology, epidemiology and approaches to management. Minerva Anestesiol 2003;69:438-441. [Medline] [Free Full text]

2. Sessler DI. Temperature monitoring. In. Miller RD. Ed. Aesthesia. New York, Edinburgh, London, Madrid, Melburn, Milan, Tokyo. Churchill Livingston. 2005. 1363-82.

3. Horne EP, Schroeder F,Wilheim S, Sessler DI, Standl T, Busche K, Esch JS. Postoperative pain facilitates nonthermoregulatory tremor. Anesthesiology 1999:91(4):979-81. [Medline]

4. Eherhart LH, Dodoerlein F, Eisenhardt G et al. Independant risk factors for postoperative shivering. Anesth Analg 2005;101:1849-57. [Medline] [Free Full Text]

5. Alfonsi P, Norrdine K, Adam F, Chauvin M,

Sessler DI. The effect of postoperative skin-surface warming on oxygen consumption. Anaesthesia. 2003;58(12):1228-1234. [Medline] [Free Full Text]

6. Kranke P, Eberhart LH, Roewer N, Tramer MR, Pharmacological treatment of postoperative shivering: a quantitative systematic review of randomised controlled trials. Anesth Analg 2002;94:453-6 . [Medline] [Free Full Text]

7. Witte JD, Sessler DI. Perioperative shivering: Physiology and Pharmacology. Anesthesiology 2002;96:467-84. [Medline] [Free Full Text]

8. Sagir O, Gulhas N, Toprak H, Yucei A, Begec Z, Ersoy O. Control of shivering during regional anaesthesia: prophylactic ketamine and granisetron. Acta Anaesthesiol Scand 2007;51(1):44-48. [Medline]

9. Joshi SS, Arora A, George A, Shidhaye RV. Comparison of intravenous butorphanol, ondansetron and tramadol for shivering during regional anesthesia: A prospective randomized double-blind study. Anaesth Pain & Intensive Care 2013;17(1):33-39

10. Powell RM, Buggy DJ. Ondansetron given before induction of anesthesia reduces shivering after general anesthesia. Anesth Analg 2000;90(6):1423-1427. [Medline] [Free Full Text]

11. Ozer AB, Tuson F, Demirel I, Unlu S, Bayar MK, Erhan OL. The effects of anesthetic technique and ambient temperature on thermoregulation in lower extremity surgery. J Anesth; 2013: DOI 10.1007/s00540-13-1555-2. [Medline]

REFERENCES

6 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

eDIToRIAL VIeW

Postoperative nausea and vomiting (PoNV): A cause for concernKhalil Ullah Shibli*

*Consultant Anesthesiologist, Clinical Senior Lecturer Yong Loo Lin School of Medicine National University of Singapore (Singapore) 768828

Correspondence: Dr.Khalil Ullah Shibli, Consultant Anesthesiologist, Khoo Teck Puat Hospital 90 Yishun Central Singapore 768828: Shibli.khalil@alexandrahealth.com.sg

SUMMARYPostoperative nausea and vomiting (PONV) has been a cause for concern, not only for the anesthesiologist but also for the patients. It is troublesome and may cause many untoward physiological consequences. Various authors have studied risk factors associated with it and management strategies, but the results have been confusing. Many new drugs have been developed for preventing and treating PONV, including ondansetron and palonosetron, and the research for the more effective and safe anti-emetic drug continues. This editorial compliments an original article being published in this issue of ‘Anesthesia, Pain & Intensive Care’ on the same topic.

Key words: Postoperative nausea and vomiting; PONV; Ambulatory surgery; Ondansetron; Palonosetron; Prevention; Prophylaxis

Citation: Shibli KU. Postoperative nausea and vomiting (PONV): A cause for concern. Anaesth Pain & Intensive Care 2013;17(1):6-9

Postoperative nausea and vomiting (PONV) is a cause for concern, not only for the anesthesiologist but regarded as the most undesirable morbidity by the patients as well.1 PONV is a debilitating morbidity that may have serious consequences including dehydration, electrolyte imbalance (resultant cardiac arrhythmias), wound dehiscence, and post-surgical haemmorhage. The indirect effects include delayed discharge from the PACU, unplanned hospital admissions in day stay surgery, longer hospital stay for inpatients and adds to the overall cost of the operation. Parra-Sanches et al2 reported an incidence of PONV in ambulatory surgery as 37% during hospitalization, 42% on the first postoperative morning and 49%.by the third postoperative morning. Patients with PONV spent one hour longer in the postanesthesia care unit than patients without PONV. Nursing time spent was significantly greater with an increase in total cost of postoperative recovery. The nuisance and recall value of PONV is such that patients have expressed their willingness to pay for the treatment of PONV.1

There has been extensive research regarding the etiology, prophylaxis and treatment of PONV. It has been suggested that the etiology of PONV is multifactorial. They identified patient, anesthesia,

and surgery related risk factors.3,4 The search for the ‘independent prediction risk factors’ for PONV has lead researchers to devise ‘PONV prediction scoring systems. Apfel et al devised a simplified 0-4 point score for four independent risk predictors. The female patient, young age, history of PONV or travel sickness and high risk surgery were identified.4 The estimated probability of PONV was 10%, 21%, 39%, and 78% with 0, 1, 2, 3, and 4 risk factors, respectively.4 A large prospective multicenter study of 2,170 adults under general anesthesia in ambulatory settings in the United States between 2007 and 2008 assessed post discharge nausea and vomiting (PDNV) from discharge until the end of the second postoperative day. It found that about one in four patients suffered from PONV, and identified five independent predictors i.e. female gender, age less than 50 years, history of nausea and/or vomiting after previous anesthesia, opioid administration in the postanesthesia care unit and occurrence of nausea in the postanesthesia care unit. The estimated probability of PDNV was 7%, 20%, 28%, 53%, 60%, and 89% with 0, 1, 2, 3, 4 and 5 risk factors, respectively.5 The authors suggests that PDNV affects a substantial number of patients after ambulatory surgery and their recently validated simplified risk score system will help identify patients who would benefit from long-

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 7

editorial view

acting prophylactic antiemetics at discharge from the ambulatory care center.4,5 However, it is of note that PDNV has not been well studied in the literature perhaps due to logistics involved in a day-stay patient follow-up seriously limits tracking of patients for PONV at home. This area deserves more attention. Other researchers identified young, female, non smoker, with a history of PONV and travel sickness undergoing a surgical procedure likely to last more than 60 minutes, as independent PONV predictors.6 Both the scoring systems predicted between 7-89% independent predictors for PONV.4,6 Van Den Bosch et al validated these two PONV prediction scoring systems.7 Combining these two systems, female gender, history of PONV and motion sickness, postoperative use of opioids, non- smokers, duration of surgery > 60 minutes and age <60 years emerged as an independent predictors for PONV.In a systematic review of prospective studies (n>500 patients) Apfel et al8 analysed 22 studies and found similar most reliable independent predictors of PONV. More importantly, the review discouraged the use of widely held beliefs about certain factors such as preoperative fasting, menstrual cycle, and the type of surgery as the predictors of PONV since no or insufficient evidence is available to substantiate it. Similarly, obesity has not been shown to be an independent risk factor for high incidence of PONV.9

Preoperative prolonged fasting and consequent dehydration and hypovolaemia is believed to be responsible for increased incidence of PONV. In a recently published systematic review of prospective randomised controlled trials, Apfel at al10 concluded that IV crystalloids were associated with a lower incidence of several PONV outcomes but a number of PONV outcomes failed to reach statistical significance, perhaps due to the lack of power. Supplemental IV crystalloids were shown to have reduced postoperative nausea (PON) in early, late and overall perioperative phase. The incidence of postoperative vomiting (POV) in early and late phases remains unaffected by the supplemental IV fluid administration although overall risk of POV was reduced.The authors recommended studies sufficiently powered for the less frequent outcomes (e.g. POV) to ascertain the value of supplemental IV fluid administration routinely. It can be, however, suggested that a judicious use of IV fluid administration (to cover preoperative fasting), avoidance of known emetic agents and early resumption of clear oral fluids may help reduce the unnecessary incidence for patient discomfort and hence PONV.

There is a no excuse for us as an anesthesiologist not to take appropriate active measures to prevent this debilitating morbidity since the PONV predictors / risk factors are identified, validated and widely published. In reality, the patient factors are hard to modify or controllable. Nevertheless, anesthetic factors should be modified and a ‘PONV free’ anesthesia technique may be tailored for an individual patient with high predictors. The debate is still alive whether or not to administer prophylactic antiemetics in every patient of ‘zero’ score that carries a risk of 7%-10% PONV.3-5 Traditionally, the words ‘prevention’ or ‘prophylaxis’ are used and aim for adequate anticipated PONV management. Habib and Gan have not advocated prophylaxis for patients at low risk for PONV;3 however, they recommended prophylaxis for patients at moderate risk for PONV, using a single antiemetic or a combination of two agents. Even more important recommendation is to adopt a ‘multimodal approach’ incorporating steps to keep the baseline risk of PONV low and consider double and triple antiemetic combinations for patients at high risk for PONV.4 Since there are multiple inputs for nausea and vomiting, the drug therapies are specific to receptor antagonism, which include antihistamines, anti-dopamine, anticholinergic, and 5-Hydroxytryptamine [5-HT3] receptor antagonists, that are widely used as monotherapy or in combination. Dexamethasone and now Neurokinin 1 (NK-1 RA) - a substance P receptor antagonist, have been added to the antiPONV armamentarium. Substance P, a regulatory neuropeptide, binds to neurokinin-1 (NK1) receptors and is competitively inhibitsed by the NK-1 receptor antagonist. Preoperative administration of aprepitant (a neurokinin-1 antagonist) is effective in reducing both vomiting and nausea for up to 48 h after surgery.11,12 Pre-hydration with oral carbohydrate containing clear fluids up to 2 h before surgery also reduces PONV.13 In the 24-h postoperative period, 40 mg aprepitant may be superior to ondansetron in reducing PONV. Recommendation varies regarding prophylactic us of anti-emetics or whether to use monotherapy aor a combination of drugs. Double and triple antiemetic combinations were recommended for patients at high risk for PONV. 14-16

The prophylactic antiemetic should not be repeated if PONV occurs within 6 hours after the end of surgery. Instead, antiemetic drug acting at a different receptor should be used. Dexamethasone and transdermal scopolamine may not be an appropriate choice if an emetic episode occurs more than 6 h after surgery. There is increasing evidence that the combination of several potentially beneficial factors (multimodal approach)

8 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

postoperative nausea and vomiting

may lead to an improved outcome. The optimum cost-effective approach to the management of PONV will differ between an ambulatory centre and an inpatient hospital setting.3 Dexamethasone is widely used as one of the main single dose antiemetic in current anaesthetic practice. The right dose of dexamethasone for PONV prevention has been studied and a 4-5 mg dexamethasone seems to be as effective as 8-10 mg as a single drug or as a combination therapy. These findings do support the current recommendation of the SAMBA (Society of Ambulatory Anesthesia) guidelines for PONV that favors the 4-5 mg dose regimen of systemic dexamethasone.17-20 Combination anti-emetics may be equally effective. However, for economy, cost and apparent safety, dexamethasone at a dose of 4 mg is an attractive first-line agent for prophylaxis against postoperative nausea and vomiting.19,20

SAMBA guidelines recommend the identification of the primary risk factors for PONV in adults and postoperative vomiting (POV) in children. The SAMBA experts panel also recommended to establish factors that reduce the baseline risks for PONV in addition to determine the most effective anti-emetic monotherapy and combination therapy regimens for PONV/POV prophylaxis. The panel of experts recommended use of pharmacologic and non-pharmacologic approaches and emphasise to ascertain the optimal approach of treatment of PONV with or without PONV prophylaxis and determine the optimal dosing and timing of antiemetic prophylaxis. Cost evaluation, justification and creation of an algorithm for patients at high risk of PONV with effective treatment strategies is also recommended. A planned multimodal algorithm starting in the preoperative area can significantly reduce the incidence of PONV.21 Proper risk assessment, risk reduction, and targeted therapy while matching the number of risk with the number of anti-emetics administered. In authors opinion, most patients present with at least one

Apfel criteria risk factor, authors’ preference is to start with a minimum of two anti-emetics i.e. dexamethasone 4 mg soon after induction and ondansetron 4 mg 20 min before the end of surgery. They recommended addition of other groups of anti-emetics depending on other risk factors. However the efficacy of the multimodal technique in preventing PDNV cannot be confirmed with the available evidence. Serotonin antagonists palonosetron is an effective, long-acting antiemetic.21,22 The PONV prevention strategy must include a careful history taking to identify patient factors, recognising surgical factors, and avoiding use of any agent which has known emetic properties. Employing a meticulous technique for hand mask ventilation (without inflating stomach) and avoiding emesis inducing drugs for general anesthesia and pain management may help in reducing if not eliminating completely the occurrence of PONV. Avoiding general anesthesia and sole use of regional techniques and peripheral nerve blockade may preclude PONV from the list of complications. However, hypotension induced vomiting as a result of intrathecal or epidural analgesia may continue in the postoperative phase, if not adequately treated. Propofol based total Intravenous anesthesia (TIVA) may be employed to avoid administration of volatiles and nitrous oxide. Managing pain with multimodal techniques and drugs like local anesthetics, Paracetamol and non-steroidal, provide an opportunity to use lowest possible dose of opioids. Adequate intravenous hydration with crystalloids and colloids and administration of 100% oxygen during and post anesthesia recovery phase may reduce the incidence of PONV. New drugs are being constantly developed, but with a variable blessing. Palonosetron is one such drug and it has been shown by Shadangi BK et al in this issue to be more effective than ondansetron in reducing nausea, but almost equally effective in prevention of PONV.23

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 9

editorial view

1. Gan TJ, Sloan F, Dear GL, El-Moalem HE, Lubarsky DA. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesth Analg 2001;92:393-400 [Medline] [Free Full Article]

2. Parra-Sanchez I, Abdallah R, You J, et al. A time-motion Economic Analysis of Postoperative Nausea and Vomiting in Ambulatory Surgery. Can J Anaesth. April 2012;59(4):366-75. [Medline] doi: 10.1007/s12630-011-9660-x.

3. Habib AS, Gan TJ. Evidence-based management of postoperative nausea and vomiting: a review. Can J Anaesth. 2004 Apr;51(4):326-41. [Medline]

4. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology 1999;91:693–700. [Medline] [Free Full Article]

5 - Apfel CC, Philip BK, Cakmakkaya OS, Shilling A, Shi YY, Leslie JB, et al. Who Is at Risk For Postdischarge nausea and Vomiting After Ambulatory Surgery? Anesthesiology 2012 Sep;117(3):475-86. [Medline] [Free Full Article] [Free Full Article]

6- Koivuranta M, Laara E, Snare L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia 1997;52:443-449 [Medline]

7- Van Der Bosch JE, Kalkman CJ, Vergouwe Y, Van Klei WA, Bonsel GJ, Grobbee DE, Moons KG. Assessing the applicability of scoring systems for predicting postoperative nausea and vomiting. Anaesthesia 2005;60:323-331 [Medline]

8- Apfel CC, Heidrich FM, Jukar-Rao S, Jalota L, Hornuss C, Whelan RP, et al. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth. 2012 Nov;109(5):742-53. [Medline] doi: 10.1093/bja/aes276

9- Kranke P, Apfel CC, Papenfuss T, Rauch S, Löbmann U, Rübsam B, et al. An increased body mass index is no risk factor

for postoperative nausea and vomiting; A systematic review. Acta Anaesthesiol Scand. 2001 Feb;45(2):160-6. [Medline]

10- Apfel CC, Meyer A, Orhan-Sungur M, Jalota L, Whelan RP, Jukar-Rao S. Supplemental intravenous crystalloids for the prevention of postoperative nausea and vomiting: quantitative review. Br J Anaesthesia 2012 Jun;108(6):893-902. [Medline]

11 Diemunsch P, Gan TJ, Philip BK, Girao MJ, Eberhart L, Irwin MG, et al. Single-dose aprepitant vs ondansetron for the prevention of postoperative nausea and vomiting: a randomized, double-blind phase III trial in patients undergoing open abdominal surgery. Br J Anaesth 2007;99:202–11 [Medline]

12 Gan TJ, Apfel CC, Kovac A, Philip BK, Singla N, Minkowitz H, et al. A randomized, double-blind comparison of the NK1 antagonist, aprepitant, versus ondansetron for the prevention of postoperative nausea and vomiting. Anesth Analg 2007;104:1082–9 [Medline] [Free Full Article]

13 Jensen K, Kehlet H, Lund CM. Post-operative recovery profile after laparoscopic cholecystectomy: a prospective, observational study of a multimodal anaesthetic regime. Acta Anaesthesiol Scand 2007;51:464–71 [Medline]

14- Diemunsch P, Apfel C, Gan TJ, Candiotti K, Philip BK, Chelly J, et al. Preventing postoperative nausea and vomiting: post hoc analysis of pooled data from two randomized active-controlled trials of aprepitant. Curr Med Res Opin 2007;23:2559-65 [Medline]

15- Scuderi PE, James RL, Harris L, Mims GR. Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment. Anesthesiology 1999;90:360–71. [Medline] [Free Full Article]

16- Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, et al. Consensus Guidelines

for Managing Postoperative Nausea and Vomiting. Anesth Analg 2003;97:62–71 [Medline] [Free Full Article]

17- De Oliveira GS Jr, Castro-Alves LJ, Ahmad S, Kendall MC, McCarthy RJ. Dexamethasone to Prevent Postoperative Nausea and Vomiting: An Updated Meta-Analysis of Randomized Controlled Trials. Anesth Analg 2013;116:58–74 [Medline] [Free Full Article] doi: 10.1213/ANE.0b013e31826f0a0a.

18- Henzi I, Walder B, Tramer MR. Dexamethasone for the Prevention of Postoperative Nausea and Vomiting: A Quantitative Systematic Review. Anesth Analg 2000;90:186–94 [Medline] [Free Full Article]

19- Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I, et al. A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting. N Engl J Med 2004; 350:2441-2451 [Medline] [Free PMC Article]

20- Gan TJ,. Meyer TA,. Apfel CC, Chung F, Davis PJ, Habib AS, et al. Society for Ambulatory Anesthesia (SAMBA) Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105;6:1615–28 [Medline] [Free Full Article]

21- Chandrakantan A, Glass P. S. A. Multimodal therapies for postoperative nausea and vomiting, and pain. Br J Anaesthesia 107 (S1): i27–i40 (2011)

22. Apfel CC, Kranke P, Eberhart LHJ, Roos A, Roewer N. Comparison of predictive models for postoperative nausea and vomiting. Br J Anaesthesia 2002; 88: 234–40. [Medline]

23. Shadangi BK, Agrawal J, Pandey R, Kumar A, Jain S. Mittal R and Chorasia. A prospective, randomized, double-blind, comparative study of the efficacy of intravenous ondansetron and palonosetron for prevention of postoperative nausea and vomiting. Anaesth Pain & Intensive Care 2013;17(1):55-58

REFERENCES

10 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

sPecIAL ARTIcLe

Termination of ventilatory support of a patient under compulsion, who is not yet brain deadS.K.Malhotra, MD

Professor of Anesthesiology and Intensive CarePostgraduate Institute of Medical Education and Research (PGIMER), Chandigarh (India) 160012

Correspondence: Professor S.K. Malhotra, MD, Department of Anesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh (India) 160012; E-mail: drskmalhotra@yahoo.com; Tel: 0091-9814435137

SUMMARYClinicians are more comfortable psychologically in withholding a treatment than withdrawing it. Reasons for this are related to the fact that withholding is passive, whereas withdrawing is active and associated with a greater sense of moral responsibility. Withdrawing or terminating ventilation in Intensive Care Unit (ICU), even in a terminally sick patient, needs thoughtful review, particularly in those patients who are not yet brain dead. So many arguments may be offered against termination of ventilatory support. Ventilation is a part of palliative care which is always instituted to improve the quality of life and to relieve physical as well as psychosocial problems. Age is a very important factor as younger patients have a greater chance to improve than elderly, if the brain is not yet dead. Even during end of life care, not only ventilation is continued, but antibiotics, nutrition and care of bed-sores etc is also continued. As far as moral principles are concerned, termination of ventilation or withholding it, are equivalent in terms of medical ethics. Dignity of dying is as vital and important as dignity of living. One can always justify continuation of ventilation on ethical grounds. There is clinical precedence for this practice.In the opinion of the Supreme Court, withdrawing of life support should be considered synonymous as a kind of euthanasia. So, the termination of ventilation under compulsion would stand illegal and unlawful. Discontinuation of ventilation on economic reasons must be considered immoral and irrational. Sometimes the decision of terminating ventilatory support may be taken in the absence of interdisciplinary communication or that with the family of the patient. Many religious beliefs argue against the termination of ventilation. There are some religious groups who even challenge the existing brain death criteria.I would suggest that all these factors should be considered before taking the decision to terminate the ventilatory support under compulsion in a terminally sick patient, whose is not yet brain dead. Key words: Brain death; Brain death criteria; Ventilatory support; Critical Care UnitsCitation: Malhotra SK. Termination of ventilatory support of a patient under compulsion, who is not yet brain dead. Anaesth Pain & Intensive Care 2013;17(1):10-13

Advances in technology and development of modern gadgets have made long term survival possible for the patients in Critical Care Units.1,2 But the debate remains regarding recommendations of end-of-life procedures, such as, terminating the ventilatory support. There are scores of concensus-meetings, unanimities and guiding principles in the literature that may help taking decision in this vital subject.3-5 The patients on ventilatory support with no brain death may be suffering from end-stage malignancies, nonmalignant end-stage diseases of different organ systems and patients with quadriplegia. Such patients may be in reversible coma or other critical conditions that may or may not be retrievable.6-8

There are various factors that play a crucial role in decision making, e.g. opinion of the physicians and that of relatives of the patient or the patient himself. The opinion to terminate the ventilatory support may be influenced by the religious faith, traditions and ethnicity of a particular nation. Though the incidence of decision making to terminate the life-supporting procedures is on the rise in recent years, it cannot be justified morally or ethically; since a commercial angle has been playing in these as a major factor. The decision makers give more weightage to cost-benefit aspect which is not always the correct approach. Palliative care: The patients may be on ventilator

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 11

special article

to improve the quality of life that involves various disciplines of medical practice.9,10 It may relieve physical symptoms as well as reduce psychosocial problems. Ventilation may be a part of palliative care.The age factor: There is a sequential relationship between age and disease.11 There is increased incidence of diseases in the elderly due to age-related physiological changes. There are more chances of retrieval in younger patients. The basic principles of managing chronic progressive disease in old age are usually quite different from that in younger patients. In both medical and surgical fields, it is difficult to diagnose and treat the elderly patients. In the end-stage phase, this problem increases manifolds. So, age is also a factor before terminating the ventilatory support.End of life care: Principally, End of Life Care means the care of a dying patient. It is not only intended to manage the symptoms but provides psychological support as well. The invasive procedures and aggressive management are either not initiated or are withdrawn. So, End of Life Care is provided to patients with end stage disease, in the absence of reversible factor, after failure of all forms of treatment, written consent of patient and relatives and explanation of issues of benefit and burden.12,13 Termination of ventilation should not be done in case there are even minimal chances of reversibility of complication or exacerbation of the disease. In addition to continuation of ventilation, routine antibiotics, care of bed sores and procedures such as incision-drainage of pus collection must be carried out.Moral principles: Since time immemorial, moral codes have been followed in medical care of patients.14,15 The implementation and acceptance of these principles may vary in various countries and cultures.16,17 Family and social traditions also play a role. The termination of ventilation under compulsion would amount to euthanasia which is not permissible in all the countries. However, if the disease is irreversible and end-stage the patient and relatives may refuse the aggressive treatment and invasive procedures. The physicians have the moral duty to keep the patient comfortable. The termination of ventilation or withholding it, are equivalent in terms of medical ethics. Dignity of death is as important as the dignity of living. Religious factors: Religion is an important determinant of attitudes toward dying, death, and end-of-life care. Basically, there is no controversy in relation to end of the earthly life in various religions. More or less all religions maintain the sanctity of the dying and of the death and discussion of religious and spiritual issues should not be ignored. In Islam, atmosphere of divinity around dying patient, recitation of holy verses and performance of last rites and rituals are highly valued.18 In Hindu faith, it is significant to die a peaceful death to attain ‘Mukti’ i.e.

liberation from life-death cycle. In practice, these values get violated in a dying patient in hospital. In orthodox Jews, law allows life-sustaining treatments to be withheld, but withdrawal of continuous interventions is forbidden because it is regarded as an act to shorten life. In general, it is believed by all religions that if you cannot give life, you have no right to take it away. So, the termination of ventilation under compulsion, particularly in the absence of brain death, is not at all permissible as per religious point of view.

Legal aspects and end of life: Care of patients with end stage disease involves difficult medical decisions. To avoid the dilemmas of such decisions, physicians take the help of the court for its directions and guidance. To prevent the medical misconduct in healthcare practice, there are various legal issues invoved.19-21 Physicians must follow accepted ethics and professional guidelines in order to take appropriate medical decisions. Although, each patient is individual and different, the management is based upon similar principles. The termination of ventilation under compulsion does not have legal support in most of the countries, but laws may vary from country to country. Ethical principles of continuing ventilation: The ethical principles dictate that first of all we must act in the interest of the patient. In the ICU care, however, life support may be manipulated in many ways that may not be, strictly speaking, in the interest of the patient. This is seen during the family’s adjustment phase of understanding the disease and accepting the terminal phase of illness. There may be some conflict or disagreement with the recommendations of the ICU team. This may be under the guise of acting in the interest of the patient but is, in reality, acting in the emotional interests of the family. There are compassionate reasons to extend ventilation, e.g. in wait for some family members to arrive from overseas, or not to let the patient die on a special day (Christmas or a birthday). One can ethically justify extension of ventilation. There is clinical precedence for this practice.A majority of Canadian intensivists are in favour of extending ventilation for organ donation. In response to the survey question ‘in the setting of acute brain injury, would you extend the duration of ventilatory support for brain death to potentially occur’, 68% of respondents replied yes.22

Personal choice regarding care: Though existing laws in the current era lay stress on individual choice to decide the type of care, it is important to emphasise that the patient and the relatives must be aware of the nature, course, complications and the prognosis of the disease before they force the physicians to terminate the ventilation. It is rather strange that consent is required

12 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

termination of ventilatory support under compulsion

to start a therapy but not for withholding. For instance, a surgery cannot be performed without an informed consent, but postoperative ventilation can be started and maintained without it. The relatives who want the termination of ventilation may argue that they did not give consent for prolonged continued ventilation and thus it should be terminated. In such situation, the law of the land would prevail based on the various factors, especially the factor of brain death. Ventilatory life support and legal issues: In the end-stage phase, ventilatory support itself leads to distress and despondency, particularly if the patient is not unconscious. Invariably, it is impossible to wean the patient off the ventilator in the terminal stages of disease. Both withdrawal and continuation of ventilation are, of course, medical decisions. Usually, there should be no medical or legal hassle in withdrawing the ventilatory support if the patient’s condition is irretrievable.23 It may be argued that if assisted ventilation has not been proved to be productive and beneficial to the patient, it should be discontinued. But if the brain is not yet dead, legal troubles may ensue. The guidelines regarding withdrawal of life support have been issued by the author’s institute,24 but their application has to be governed in accordance with decision of Supreme Court of India.25 In the opinion of the Supreme Court, withdrawal of life support should be considered synonymous with a kind of euthanasia. So, the termination of ventilation under compulsion would stand illegal and unlawful. Economic Considerations: The issue of cost involved in continuing the ventilatory support is usually considered immoral and irrational. It is true that the cost of critical care is high and that it may have to be continued for many weeks to months, ethical issues of critical care cannot be dismissed purely on the ground of emotional justification. Although in the USA, medical bills contribute to about 50% of bankruptcies; termination of ventilation in a patient with brain not yet dead, would not be justified on economic grounds. Interdisciplinary communication: Ventilatory care in most ICUs is provided by anmultidisciplinary team that includes nurses and physicians of different specialties. The decision to terminate the ventilation should be made after discussions between all members of the team. But the collaboration in between the team members varies in different countries. Poor interdisciplinary collaboration may result in features of burnout, depression, and post-traumatic stress among ICU personnel. Moreover, disagreements between physicians in the ICU are frequent regarding end of life care such as the decision regarding termination of ventilation.26

Communication with family: The physicians treating a critically sick patient must reveal the information about the condition and prognosis to the patient and the family members to help them decide the treatment preferences. A ‘shared decision’ means that ‘the responsibility for decisions is shared jointly by the physician and the patient’s family’.27 But significant differences are there in the extent of involvement of the patient and the family in the termination of ventilation. In Asia, family involvement may be even 100% in decision making.28

Most families prefer the physician to recommend about termination of ventilation in Europe.29 But in few isolated instances, physician is under compulsion by the family to terminate the ventilatory support. Physicians must consider the variety of attitudes present in the multicultural society in the modern era. Only half of the families can understand basic information about diagnoses, prognoses or treatment options after discussion with the physicians.30

Brain Death Determination: Brain death is defined as the irreversible loss of function of the brain, including the brainstem. Primary cause of brain death may be head injury or intracranial hemorrhage, while in Medical or Surgical ICU, hypoxic brain damage is the major cause. Before discontinuing the cardiorespiratory support the criteria for brain death must be fulfilled. There are various steps to reach the determination of brain death.Step 1. Establish cause of coma and irreversibility of coma. Step 2. Document clinical assessment of brain stem reflexes.Step 3. Perform and document apnea test. Step 4. Perform ancillary testing, if indicated. Step 5. Implement religious or moral objections to brain death standards.Step 6. Certify brain death.Step 7. Discontinue cardiorespiratory support. Brain death for the purposes of organ donation: Extending ventilation to allow brain death to occur for the purposes of organ donation is practiced, particularly if expressed wishes of the patient are known.31 Donation decisions depend on attitude toward donation and the religious, cultural, and knowledge-based beliefs that comprise the attitude. “Brain Death” is not Death: ‘Pontifical Academy of Sciences’ hosted a meeting in 2005 at the Vatican entitled “The Signs of Death.” The meeting was convened at the request of Pope John Paul II to reassess the signs of death and verify at a purely scientific level, the validity of brain-related criteria for death. They concluded, “When a vital

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 13

special article

organ ceases to function, death can result. On the other hand, medical intervention can sometimes restore the function of the damaged organ, or medical devices (such as pacemakers and heart-lung machines) can preserve life. The observation of a cessation of functioning of the brain does not in itself indicate destruction of brain, much less death of the person. There is overwhelming medical and scientific evidence that the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem) is not proof of

death. The complete cessation of brain activity cannot be adequately assessed. Irreversibility is a prognosis, not a medically observable fact. We now successfully treat many patients who in the recent past were considered hopeless.” Such concepts, though sponsored by religious bodies, also suggest that termination of ventilation in end stage patients should not be undertaken even when physicians are under compulsion.

1. Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 1998,158:1163-1167. [Medline] [Free Full Article]

2. Ferrand E, Robert R, Ingrand P, Lemaire F, French LATAREA Group. Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. French LATAREA Group. Lancet 2001;357:9-14. [Medline]

3. Truog RD, Cist AF, Brackett SE, Burns JP, Curley MA, Danis M, et al. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001;29:2332-2348. [Medline]

4. Sprung CL, Carmel S, Sjokvist P, Baras M, Cohen SL, Maia P, et al. ETHICATT Study Group: Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: the ETHICATT study. Intensive Care Med 2007; 33:104-110. [Medline]

5. Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, et al. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 2004; 30:770-784. [Medline]

6. Stapleton RD, Curtis JR. End-of-life considerations in older patients who have lung disease. Clin Chest Med 2007 Dec;28(4):801-11. [Medline] [Free PMC Article]

7. Sprung CL, Woodcock T, Sjokvist P, Ricou B, Bulow HH, Lippert A, et al. Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study. Intensive Care Med. 2008 Feb;34(2):271-7. [Medline]

8. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine. Crit Care Med 2008 Mar;36(3):953-63. [Medline]

9. Morrison RS, Meier DE. Clinical practice, palliative care. N Engl J Med 2004;350:2582-90. [Medline] [Free Full Article]

10. Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ 2005;330:1007-11 [Medline] [Free PMC Article]

11. Peto R, Doll R. There is no such thing as aging. BMJ 1997;315:1030–1032. [Medline] [Free PMC Article]

12. Beauchamp, T L, Childress, J F. Principles of biomedical ethics (6th ed., pp. 38-39). New York, NY: Oxford University Press. 2009: 155-58.

13. Brody H, Campbell ML, Faber-Langendoen K, Ogle KS. Withdrawing intensive life-sustaining treatment—recommendations for compassionate clinical management. N Engl J Med 1997; 336:652-657. [Free Full Article]

14. Managing death in the intensive care unit. Transition from Cure to Comfort, Oxford: Oxford University Press, 2001.

15. Finucane TE. How gravely ill becomes dying: a key to end-of-life care. JAMA 1999 Nov 3;282(17):1638-45. [JAMAnetwork]

16. Fuchs VR. Who Shall Live ? Health, Economics, and Social Choice. New. York, Basic Books Inc, 1974.

17. Paris JJ, Reardon FE. Dilemmas in intensive care medicine: An ethical and legal analysis. J Intensive Care Med 1986;1:75-90. [Sagepub] doi: 10.1177/088506668600100204

18. Lo B, Ruston D, Kates LW, Arnold RM, Cohen CB, Faber-Langendoen K, et al. Discussing religious and spiritual issues at the end of life. A practical guide for physicians JAMA 2002;287:749–754. [Medline]

19. Medical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs. JAMA 1999 Oct 13;282(14):1331-2. [Medline]

20. Luce JM. Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists. Crit Care Med 1995 Apr;23(4): 760–766 [Medline]

21. Meisel A. Legal myths about terminating life support. Arch Intern Med 1991;151: 1497-1502 [Medline]

22. Shemie SD, Cupido CM. The management of brain death and organ donation in Canadian

children [abst]. Pediatr Crit Care Med 2000; 1:A46.

23. Consensus statement of the Society of Critical Care Medicine’s Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997 May;25(5):887-91. [Medline]

24. Guide lines for withdrawal of Treatment of Irreversibly Critically Ill Patients on Assisted Respiratory Supports. Available from: www.pgimer.nic.in (Accessed on 25.12.2012)

25. Supreme Court of India: Aruna Ramchandra Shanbaug vs Union Of India and others(2011) Writ petition (CRL) No.115 of 2009.

26. Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinová K, Lafabrie A, et al. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med 2009;180:853–60. [Medline] [Free Full Article]doi: 10.1164/rccm.200810-1614OC. Epub 2009 Jul 30.

27. Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, et al. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 2004;30:770–84. [Medline]

28. Mani RK, Mandal AK, Bal S, Bal S, Javeri Y, Kumar R, et al. End-of-life decisions in an Indian intensive care unit. Intensive Care Med 2009;35:1713–19. [Medline] doi: 10.1007/s00134-009-1561-x. Epub 2009 Jul 1.

29. Heyland DK, Rocker GM, O’Callaghan CJ, Dodek PM, Cook DJ. Dying in the ICU: perspectives of family members. Chest 2003;124:392–97. [Medline]

30. Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 2000;28:3044–49. [Medline]

31. Radecki CM, Jaccard J. Psychological aspects of organ donation: a critical review and synthesis of individual and next-of kin donation decisions [review]. Health Psychol 1997;16:183-195. [Medline]

REFERENCES

14 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

oRIGINAL ARTIcLe

sedation with propofol during combined spinal epidural anesthesia: comparison of dose requirement of propofol with and without BIs monitoring R. K. Verma, MBBS, DA, MD*, Anil K Paswan, MBBS, MD**, Shashi Prakash, MBBS, MD***, Surender K. Gupta****, P.K. Gupta, MBBS, DA, MD*

*Professor; ***Assistant Professor; ****Senior residentAll India Institute of Medical Sciences, New Delhi (India)

**Assistant ProfessorDepartment of Anesthesiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005 (India)

Correspondence: Dr Anil K Paswan, Department of Anesthesiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005 (India); Mobile: +919794855871; E-mail: dranil1973@gmail.com

ABSTRACTBackground: Bispectral (BIS) monitoring provides an objective, non-invasive measure of the level of consciousness in sedated patients. Sedation has been shown to increase patient satisfaction during regional anesthesia. Propofol is extensively being used as a sedative, providing sedation while patients remain cooperative and can be easily aroused. In this study, we sought to determine whether BIS is a useful adjunctive manoeuvre to reduce the sedative dose of propofol by using BIS.

Methodology: Forty patients of ASA grade I and II, weighing between 30 to 60 kg, undergoing elective gynecological surgery of about 60 minutes duration were included in the study, and randomly divided into two groups. All patients received combined spinal epidural anesthesia (CSEA). The patients in Group-P (n=20) received propofol without BIS monitoring and those in Group-PB (n=20), received propofol under BIS monitoring. Total doses of propofol consumed in all patients were calculated and compared using paired t-test. A p-value <0.05 was considered to be significant.

Results: The mean total dose of propofol consumed was 130.25 mg ± 46.95 without BIS monitoring (Group-P) compared to 68.49 mg ± 12.59 in patients (Group-PB) in which BIS was used to monitor the desired sedation level (P< 0.001). Mean dose to reach required level of sedation was also reduced (68.35 ± 21.10 vs 29.01 ± 9.45, P< 0.001).

Conclusion: Use of BIS during propofol infusion reduces requirement of propofol for sedation during regional anesthesia

Keywords: Propofol, Bi-spectral index; BIS; Combined spinal epidural anesthesia; Regional anesthesia; Gynecological surgery; Sedation level; Ramsay sedation score

Citation: Verma RK, Paswan AK, Prakash S, Gupta SK, Gupta PK. Sedation with propofol during combined spinal epidural anesthesia: Comparison of dose requirement of propofol with and without BIS monitoring. Anaesth Pain & Intensive Care 2013;17(1):14-17

INTRODUCTION Majority of the gynecological surgeries are being performed under regional anesthesia. For surgery under spinal as well as combined spinal epidural anesthesia, sedation is a valuable tool to make it more comfortable for the patient, the surgeon and the anesthetist. Propofol, midazolam and many other sedative agents

are commonly used for this purpose during regional anesthesia, especially in young adults.1,2 Many previous studies have proved that subarachnoid bupivacaine enhances the hypnotic effects of midazolam, thiopentone and propofol.3,4 Due to decrease in dose requirement during subarachnoid block, it is essential to precisely titrate the amount of drug actually needed,

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 15

original article

because spinal anesthesia with conventional sedative doses may led to respiratory and cardiac complications and even some cases of cardiac arrest have also been reported.5 BIS correlated well with the level of responsiveness and provided an excellent prediction of the loss of consciousness6. Bispectral (BIS) monitored guidance has a significant role in titrating the dose of intravenous sedative agents.7 We conducted this prospective study to compare the dose requirement of propofol, recovery time, recall and the cost, with or without using BIS monitoring during gynecological surgeries under combined spinal epidural anesthesia.

METHODOLOY After obtaining approval by the Hospital Ethics Committee, we studied 40 ASA grade I & II patients, in the age group of 30-50 yrs and weighing 30 to 60 kg, scheduled for elective gynecological surgery of about 60 minutes duration, in this prospective, randomized controlled trial. Written informed consent was taken from every patient enrolled in the syudy. Patients having history of allergy to propofol, any contraindications to spinal anesthesia, patients with known psychiatric illness or any previous neurological deficit were excluded from the study.Patients were randomized, by sealed envelopes, to receive propofol infusion without (Group-P, n=20) or with BIS monitoring (Group-PB, n=20). No sedative premedication and antiemetics were given to the patients. In the operating room, monitors including ECG, pulse oximetry and non-invasive blood pressure were attached. In Group-PB, electrodes (BISTM Sensor; AspectTM Medical Systems, Inc., Newton, MA, USA) were applied to the patients’ forehead to monitor the BIS (A-2000 BISTM monitor, System rev.2.1, AspectTM Medical Systems). BIS smoothing rate was set at 15 S. 10 ml/kg of normal saline solution was infused through 18G intravenous cannula to each patient as a preloading fluid before giving subarachnoid block. Baseline values of mean arterial pressure (MAP), heart

rate (HR), peripheral oxygen saturation (SpO2) and BIS were recorded. Combined spinal epidural needles (B.Braun, Melsungen AG, Germany) were used in the lateral decubitus position at L3–4 or L4–5 interspace and 4-5cm catheter was inserted in the epidural space. Anesthetic level was evaluated by the pin-prick method ten minutes after giving the block and propofol infusion (1%) was started. Patients in Group-P received propofol 1% infusion at 5 mg/kg/hr. After reaching Ramsay sedation score 3 (Ramsay sedation score)8, the dose was reduced to 3 mg/kg/hr. Patients in Group-PB received 1% infusion starting with 5 mg/kg/hr, till

BIS value reached 75 and then the dose was reduced and titrated to maintain BIS level of 65-85. MAP was maintained within 20% of baseline values using ephedrine 5 mg boluses. Bradycardia (HR<60 beats/min) was treated with atropine 0.5 mg IV. If oxygen saturation dropped <94%, oxygen was administered at 6 lit/hr using a face mask. Propofol infusion was started by an anesthesiologist, who was blinded to the study. Surgery was started immediately after achieving the required level of sedation (Ramsay sedation score 3). Onset time and the propofol dose required for the onset of required level of sedation were recorded. Heart rate, mean arterial blood pressure and oxygen saturation were recorded at 15 minutes intervals. Propofol infusion was stopped about ten minutes before completion of surgery and recovery time (BIS value 90, or Ramsay sedation score 2) was noted. Statistical analysis: After completion of the study, the data were entered into the statistical software package using Smith Statistical Package (SSP) Version 2.80. Data are presented as mean ± SD or percentage as appropriate. Comparisons between groups for patient characteristic data, onset and recovery time and propofol doses were compared using independent student’s t-test. In between two groups, comparison of incidence of complications e.g. bradycardia/tachycardia, hypoxemia, hpotension/hypertension, restlessness, Fisher’s exact probability test was applied because sample size was very small, and p-value <0.05 was expressed as statistically significant at two-tailed test. The sample size provided 80% power to detect a 20% difference between two groups.

RESULTSThere was no statistically significant differences in the groups with respect to age and weight (p >0.05) (Table-1). Anesthetic level was T6-T7 in both the groups. Time to reach required level of sedation was significantly less in Group-PB as compared to Group-P [5.85 ± 1.35 vs 16.15 ± 2.29 min; (p < 0.01)] (Table-1). Mean dose to reach required level of sedation was lower in Group-PB [29.01±9.45 Vs 68.35 ± 21.10 mg (p< 0.01)]. Mean dose to maintain sedation was also lower in Group-PB [39.49 ±8.76 Vs 61.9 ± 41.15 mg (p< 0.005)]. Mean total dose was lower in Group-PB [68.49 ± 12.59 Vs 130.25 ± 46.95 mg (p< 0.001)] (Table-2). There was a reduction in the dose of propofol by about 47% by using BIS monitoring. Duration of infusion was comparable in both groups (Table-2). Recovery time was delayed in Group-PB [9.41 ± 3.41 Vs 4.35 ± 2.01 min (p<0.001)] (Table-2). Parameters e.g. heart rate, mean arterial pressure and oxygen saturation were comparable in both groups. There was no statistically

16 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

sedation with propofol during combined spinal epidural anesthesia

significant difference in the incidence of various complications between the two groups (p>0.05) (Table-3). However complications were more common in Group-P.

DISCUSSIONThe BIS,9 an EEG derivative, has been shown to be a sensitive and simple monitor to assess the hypnotic

component of anesthesia, and the level of consciousness

during propofol sedation.6,10 Our study showed that during regional anesthesia BIS monitoring is useful in reduction in dose of propofol needed for sedation by 47%. Mean dose to reach desired level of sedation is also decreased.Spinal anesthesia itself has some sedating properties, which has been proved in many studies.11 Pollock and colleagues12 reported that in volunteers, spinal anesthesia leads to a significant decrease in BIS level. Several studies have shown that the interaction between spinal local anesthetics and sedatives leads to an augmentation of the sedation causing a decrease in the required dose of intravenous anesthetic agents.3,4 Even intramuscular injection of lignocaine or bupivacaine has some sedative effect, due to which requirement of thiopentone was decreased.13 This interaction can be explained by systemic effects of absorbed local anesthetics,14 rostral spread of local anesthetic with direct action on brain and deafferentation.15 Most speculated

mechanism for sedation during spinal anesthesia is a deafferentation phenomenon. However intravenous anaesthetic agents like propofol, thiopentone and

midazolam are associated with many complications e.g. allergic reactions, local tissue irritation, hypotension, bradycardia, apnoea and pain on injection etc. Hence, there is a need to know the minimum amount of these drugs needed to provide adequate sedation with minimum side effects. We have used BIS monitoring in our study for this purpose. Titration of anesthetic agents by BIS index appears to decrease the incidence of intraoperative awareness, currently estimated at 0.2% in healthy patients undergoing general anesthesia and 1.14% in patients undergoing cardiac surgery.12,16 BIS and auditory evoked potential (AEP) monitor (A-line AEP monitor) have been shown to be superior to the classic electroencephalographic and hemodynamic variables for predicting anesthetic conditions.17 A good correlation of BIS index and level of awareness has been demonstrated by many authors.9,10 There are some studies in which the investigators have found that BIS guided anesthesia is cost effective7,18 Murlidhar K and colleagues18 reported that BIS guided anesthesia for CABG was associated with 35.2% reduction in anesthetic agent (isoflurane) and 32% reduction in propofol requirement in another group. In the present study we noted a reduction in propofol requirement by 47%. The difference could be due to differences in BIS scoring level; in their study they kept it in between 45-55, and we kept it in between 65-85.18,19 We found that target sedation was achieved faster in the BIS guided group than the other group. This could have been due to an advantage of continuous graphical

Table 1: Demographic Data

Table 2: Doses, duration of infusion and recovery time.

Groups Group-PN = 20

Group-PBN = 20 t-value p-value

Mean age ± SD (years) 38.8 ± 10.44 39.45±6.48 0.24 > 0.05

Mean weight ± SD (kg) 47.5 ± 7.15 48.87±7.51 0.59 >0.05

Time to reach required level of sedation (Min) 16.15 ± 2.29 5.85±1.35 17.32 <0.001

Level of sensory block T6-T7 T6-T7 0 0

Groups Group-PN = 20

Group-PBN = 20 t-value p-value

Mean dose to reach required level of sedation 68.35 ± 21.10 29.01±9.45 7.61 <0.001

Mean dose to maintain sedation 61.9 ± 41.15 39.49±8.76 2.38 <0.05

Mean total dose 130.25 ± 46.95 68.49±12.59 5.68 <0.001

Duration of infusion (Min) 51.8 ± 4.351 54.65±7.64 1.46 >0.05

Recovery time (Min) 4.35 ± 2.01 9.41±3.41 5.72 < 0.001

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 17

original article

1. McClure JH, Brown DT, Wildsmith JAW. Comparison of the i.v. administration of midazolam and diazepam as sedation during spinal anesthesia. Br J Anaesth. 1983 Nov;55(11):1089-93. [Medline]

2. Mackenzie N, Grant IS. Propofol for intravenous sedation. Anaesthesia. 1987 Jan;42(1):3-6. [Medline]

3. Tverskoy M, Shagal M, Finger M, Kissin I. Subarachnoid bupivacaine blockade decreased midazolam and thiopentone hypnotic requirements. J Clin Anesth1994;6(6):487-90 [Medline]

4. Tverskoy M, Fleyshman G, Bachrak L and Ben-shlomo J. Effect of bupivacaine-induced spinal block on the hypnotic requirement of propofol. Anaesthesia 1996;51(7):652-53. [Medline]

5. Caplan RA, Ward RJ, Posner K, Cheney FW: Unexpected cardiac arrest during spinal anesthesia: A closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11. [Medline] [Free Full Article]

6. Glass P, Bloom M, Kearse L, Rosow C, Sebel P, Manberg P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanyl in healthy volunteers. Anesthesiology 1997;86(4): 836–47 [Medline] [Free Full Article]

7. Muralidhar K, Banakal S, Dinesh R. BIS guided anesthesia for off-pump CABG

is cost-effective. European Journal of Anaesthesiology. 2002;19: 5. [Free Full Article]

8. Ramsay M, Savege T, Simpson B, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974 Jun 22;2(5920):656-9. [Medline] [Free PMC Article]

9. Greenwald S, Chiang HH, Devlin P, Smith C, Sigl J, Chamoun N. Bispectral index (BIS 2.0) as a hypnosis measure (Abstract). Anesthesiology 1994;81:A477 [Google Scholar]

10. Lui J, Singh H, White PF. Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation. Anesthesiology 1996;84:64–9. [Medline] [Free Full Article]

11. Pollock JE, Neal JM, Liu SS, Burkhead D, Polissar N. Sedation during spinal anesthesia. Anesthesiology 2000;93:728–34 [Medline] [Free Full Article]

12. Donald R, Stanski, Shafer SL. Measuring depth of anesthesia, Chapter 31. In : Miller RD, editor. Miller’s Anesthesia 6 th ed. Philadelphia: Elsevier Churchill Livingstone; 2005; pp1227-64.

13. Tverskoy M, Ben Shlomo I, Vainshtein M, Zohar S, Fleyshman S. Hypnotic effect of i.v. thiopentone is enhanced by i.m. administration of either lignocaine or bupivacaine. Br J Anaesth 1997;79(6):798–800. [Medline] [Free Full Article]

14. Tverskoy M, Shifrin V, Finger J, Fleyshman G, Kissin I. Effect of epidural bupivacaine block on midazolam requirements. Reg Anesth1996;21:209–13 [Medline]

15. Eappen S and Kissin I. Effect of subarachnoid bupivacaine block on anesthetic requirements for thiopental in rats. Anesthesiology 1998; 88: 1036–42 [Medline] [Free Full Article]

16. Phillips AA. McLean RF, Devitt JH, Harrington EM. Recall of intraoperative events after general anesthesia and cardiopulmonary bypass. Can J Anaesth 1993;40:922. [Medline]

17. Schmidt GN, Bischoff P, Standl T, Issleib M, Voigt M, Schulte Am Esch J. ARX-derived auditory evoked potential index and bispectral index during the induction of anesthesia with propofol and remifentanil Anesth Analg 2003;97:139-44. [Medline] [Free Article]

18. Murlidhar K, Banakal S, Murthy K, Garg R, Rani GR, Dinesh R. Bispectral index-guided anesthesia for off-pump coronary artery bypass grafting. Ann Card Anaesth 2008;11(2):105-110. [Medline] [Free Full Article]

19. Hariharan S, Chen D, Merritt-Charles L. Off-pump coronary artery bypass surgery: anaesthetic implications and the Trinidad experience. West Indian Med J. 2006 Oct;55(5):298-304. [Medline]

REFERENCES

Table 3: Comparison of complications in two groups

Complication Group-P (n = 20)

Group-PB (n = 20) p-value

Restlessness 4(20) 3 (15)

>0.05

Awareness 3 (15) 2 (10)

O2 supplementation (SPO2 < 94%) 2 (10) 2 (10)

Hypotension 2 (10) 1 (5)

Nausea / vomiting 0 2 (10)

Pain in arm 0 1 (5)

monitoring with BIS monitor, while the sedation scores assessed in the other group were by qualitative method. We found that recovery time is prolonged in the BIS guided group; this could be due to the fact that most of the patients in our group were having BIS around 70, that’s why recovery was delayed and took time in reaching BIS of around 90 and without BIS monitoring recovery was comparatively better and statistically significant might be due to frequent awakening of patient intraoperatively to maintain Ramsay sedation

score-3 and awakening and awareness maintained postoperatively also. However, we assume that it would be unethical to keep the patients unsedated. Limitations: The study sample size was very small and plasma level of propofol was not monitored.

CONCLUSIONOn the basis of this study we can conclude that BIS should be used for monitoring the level of sedation in regional anesthesia. as it is associated with a reduction of total propofol required and hence is cost effective. Further studies should be done in this direction with a larger sample size.

Acknowledgements: We would like to thank the staff of Institute of Medical Science, BHU for their valuable support. We are also thankful to Prof. TB Singh of Department of Biostatistics for statistical analysis of the data.Funding source: There was no funding source. Conflict of interest: There was no conflict of interest from any author.

18 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

oRIGINAL ARTIcLe

Does intra-cuff alkalinized lidocaine prevent tracheal tube induced emergence phenomena in children?Mona S. Ahmady*, Sayed Sadek**, Roshdi R. Al-metwalli****Lecturer, Department of Anesthesiology, Mansoura University, Mansoura (Egypt)**Lecturer, Department of Anesthesiology, El-Fayoum University, El-Fayoum (Egypt)***Associate Professor, Department of Anesthesiology & Intensive Care, University of Dammam (KSA)

Correspondence: Roshdi R. Al-metwalli, University of Dammam / King Fahad Hospital, PO Box 40081; Al-Khobar (KSA) 31952; Tel: 0096638982219; Fax: 009668966770; E-mail: rmetwalli@yahoo.com

ABSTRACTAim: To study and investigate the efficacy of intra-cuff alkalinized lidocaine in the prevention of the endotracheal tube (ETT) induced emergence phenomena in children.

Methodology: Fifty children, ages 6-12 years, ASA physical status I-II, scheduled for elective dental surgery under N2O free general anesthesia with an expected duration of 120 min or more, were randomly assigned one of the two groups (25 patients each); lidocaine group in which the cuff of ETT was inflated with a mixture of lidocaine 2% and sodium bicarbonate 8.4% and the saline group, in which tube cuff was inflated with 0.9% saline solution.

Results: There were significant reduction in the incidence and severity (p=0.005 & p= 0.014) of cough at extubation and in the PACU (P=0.048 & P=0.014). The incidence and severity of postoperative sore throat was also reduced in the lidocaine group compared to the saline group (p=0.025 and 0.031 respectively). Moreover, there was a significant prolongation of the time to spontaneous ventilation before extubation in the lidocaine compared to the control group (16.4±3.1 min and 9.4±1.7 min respectively) with p value < 0.0001.

Conclusion: Intra-cuff alkalinized lidocaine reduces the incidence of cough, sore throat, improved ETT tolerance and inducing smooth extubation in paediatric patients, but prolongs time to spontaneous ventilation before extubation.

Keywords: Lidocaine; Alkalinization; Post-extubation; Tracheal tube cuff; Laryngospasm

Citation: Ahmady MS, Sadek S, Al-metwalli RR. Does intra-cuff alkalinized lidocaine prevent tracheal tube induced emergence phenomena in children? Anaesth Pain & Intensive Care 2013;17(1):18-21

INTRODUCTION

The fears of tracheal mucosal injury due to ischemia and subsequent subglottic stenosis have prevented widespread use of cuffed endotracheal tube (ETT) in pediatric population below the age of eight,1,2 although studies using the modern anatomically designed high-volume, low-pressure cuffs have not shown any significant increase in the incidence of post-extubation complication compared to un-cuffed ETTs.3-7 Cough and stridor (laryngospasm) are the most recorded post-extubation morbidity in pediatrics patients.8-11 Recent studies have shown that lidocaine hydrochloride placed inside an ETT cuff can diffuse across its hydrophobic membrane and topically block cough receptors in the tracheal mucosa.11,12 Moreover, alkalinization of lidocaine enhanced its diffusion across the cuff membrane and

allowed smaller amounts to be used, 40 mg, compared to 500 mg in a previous published study.13 To our knowledge intra-cuff lidocaine has been only tested in adult population. With advancement in the manufacture of pediatric cuffed tubes and the possibility to use safe small doses of intra-cuff lidocaine by its alkalinization, the anesthesiologists can use cuffed ETT’s with more confidence. The aim of our study was to evaluate the use of alkalinized intra-cuff lidocaine in pediatric patients undergoing dental surgery, and its efficacy in the prevention of the ETT induced emergence phenomena.

METHODOLOGYAfter approval from local Research and Ethics committee and written informed consents, fifty

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 19

original article

children with age between 6-12 years old, and ASA physical status I or II were enrolled in this prospective controlled, randomized, blinded study. All patients were scheduled for elective dental surgery under N2O free general anesthesia with an expected duration of 120 min or more. Any patients who had a recent attack of upper respiratory tract (URT) infection, history of bronchial asthma, or in whom intubation was difficult (two or more attempts) were excluded from the study.All patients were premedicated with 0.2 mg/kg oral diazepam 90 minutes before anesthesia induction, and xylometazoline hydrochloride 0.05% nasal drops 10 minutes before induction. After attaching standard monitors e.g. pulse oximetry, blood pressure and ECG, and pre-oxygenation for 2-3 min, a standard anesthetic technique was conducted by consultant anesthesiologist who was blind to the study design. Anesthesia was induced with fentanyl 2 μg/kg and propofol 2.5 mg/kg. Nasal tracheal intubation was facilitated with rocuronium bromide 0.6 mg/kg, using nasal RAE tube (RUSCHELIT™) with high volume, low-pressure cuff and with an inner diameter calculated according to the Khine´s formula (I.D. = age/4+3).14 Patients were randomly assigned by opening a sealed envelope into two groups (25 patients each), lidocaine group and saline group. The ETT cuff was aspirated as much as possible and then inflated with syringe loaded with either a mixture of 1.5 ml of lidocaine 2% and 1.5 ml sodium bicarbonate 8.4% (Lidocaine group) or 3 ml normal saline (Saline group). In both groups the cuff was inflated by the same anesthesiologist to prevent air leaks (minimal occlusion pressure) during the inspiratory phase of mechanical ventilation of the patient when peak airway pressure was 20 cmH2O. If the minimal occlusion pressure exceeded 20 cmH2O (the recommended upper limit intra-cuff pressure), the patient then was excluded from the study. The cuff pressure was measured using hand-held, manometer P-V gauge (Mallinckrodt Medical, St. Louis, MO) by the same anesthesiologist, who also assessed air leak by both audible technique and by observing the difference between inspiratory and expiratory tidal volume.Anesthesia was maintained with sevoflurane (2-3% end-tidal) and 50% oxygen in air. Additional boluses of fentanyl (1–2 μg/kg) were administered to maintain surgical analgesia. Mechanical ventilation was controlled and adapted to maintain end-tidal carbon dioxide at 30-35 mmHg. At the end of the surgery, sevoflurane was discontinued, the lungs were ventilated with 100% O2 and the pharynx was gently suctioned. The residual muscle paralysis was reversed by neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. Patients were extubated when they fulfilled the following criteria; (1)

Efficient spontaneous respiration (2) Ability to follow the verbal commands; and ability to do purposeful movement (attempting self-extubation) (3) Full reversal of neuromuscular block (ulnar nerve T4/T1 ratio = 1).

The time to spontaneous ventilation before readiness as well as post-extubation stridor, were recorded. Post-extubation coughing was graded and recorded based on the modified four point scale as follows; Grade 0 = No cough; Grade 1 = (Mild) single bout of cough; Grade 2 = (Moderate) more than one episodes of unsustained (≤ 5 sec) coughing and Grade 3 = (Severe) sustained (> 5 sec) bouts of coughing.

The duration of surgery and intubation were recorded. Paracetamol suppository (15 mg/kg) was inserted for postoperative analgesia. The same blinded anesthesiologist recorded coughing as above grading, and recorded sore throat and hoarseness using verbal analogue scale score (VAS: 0-10 cm) before discharge from PACU and 24 hours after tracheal extubation.

Statistics: To calculate the sample size, we estimated that using alkalinized lidocaine would decrease the rate of cough and postop erative sore throat by 30-40% as evaluated by pilot study. Based on this estimation and at a significance level of 0.05 with a power of 80%, 25 subjects were needed in each group. Demographic data, duration of surgery and intubation, the volume of alkalinized lidocaine injected into the ETT cuff and the time of spontaneous ventilation before extubation, were statistically compared using the unpaired Student’s t test. Gender and other ratios data were analyzed using Fishers exact or Chi square tests. Man-Whitney U-tests were used for non-parametric data. Statistical significance was defined as P < 0.05. Analysis was performed using Statistica software version 7.0 for windows (Statsoft, Inc).

RESULTSFifty patients participated in our study and none was excluded. There were no statistically significant differences between the two groups regarding demographic data, duration of surgery or intubation, or in the volume of alkalinized lidocaine injected into the ETT cuff (Table 1). There was significant reduction in the incidence and severity (p=0.005 & p= 0.014) of cough at extubation and in the PACU (P=0.048 & P=0.014) as well as, the incidence (p=0.025) and severity (p=0.031) of postoperative sore throat in the lidocaine group compared to the saline group (Table 2). Furthermore there was a significant prolongation of the time to spontaneous ventilation before readiness to extubation in the lidocaine compared to the saline group (16.4±3.1

20 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

intra-cuff alkalinized lidocaine and emergence phenomena

Table 1: Patient’s Demographic and operative data

Parameters Lidocaine GroupN (25)

Saline GroupN (25) P value

Age (year) 8.3±1 8.2±1 0.78Sex (M/F) 16/9 15/10 1.00Weight (kg) 30.8±3.1 30.7±3.3 0.86Intra-cuff volume injected (ml) 2.56±0.1 2.55±0.2 0.92Time of surgery (min) 134.8±10.8 133.7±11 0.70Intubation time (min) 157.5±10.8 156.2±10.7 0.65Time of spontaneous ventilation to extubation (min) 16.4±3.1* 9.4±1.7 < 0.0001

(*) Indicate significant difference.

Table 2: Tracheal tube-induced emergence phenomena; data are expressed as number (percentage), mean (SD) or median (Interquartile range)

Lidocaine Group Saline Group P value

Incidence Severity Incidence Severity Incidence Severity

CoughExtubation N=12 (48) 0.0 (0-2) N=22(88) 0.0 (1-2) 0.005* 0.014*

PACU N=1(4) 0.0 (0-0) N=7(28) 0.0 (0-1) 0.048* 0.014*

24 hours N =1 (4) 0.0 (0-0) N=2(8) 0.0 (0-0) 1.000 1.000Post-extubation stridor N=2(8) N=4(16) 0.667101Sore throatPACU N=3(12) 0.64±1.8 N=11(44) 2.16±2.8 0.025* 0.031*24 hours N=1(4) 0.12±0.6 N=7(28) 0.82±1.5 0.048* 0.0373*HoarsenessPACU N=2(8) 0.28±0.96 N=4(16) 0.52±1.2 0.667101 0.448924 hours N=0 ---- N=0 -------- ------ -------

(*) Indicate significant difference.

min. and 9.4±1.7 min. respectively) with p value <0.0001 (Table 1). The two groups showed no significant differences in either incidence of post-extubation stridor or postoperative hoarseness (Table 2).

DISCUSSIONThis is the first prospective, randomized, controlled, blind study in which the ETT cuff filled with alkalinized lidocaine was evaluated in pediatric population. It showed a significant reduction in the incidence and severity of cough at extubation and at PACU, as well as, the incidence and severity of postoperative sore throat in the lidocaine group compared to the saline group. However, the incidence and severity of both extubation stridor and postoperative hoarseness were similar in the two groups.The study of Estebe et al13,15-17 was the first study, that reported that alkalinization of intra-cuff lidocaine, increased the diffusion rate of its neutral base across the hydrophobic structure of the cuff membrane from 1% to 65% within 6 hours period. This allowed the use of a low (20-40 mg) safe and effective dose compared to a higher but risky dose (200-500 mg) of non-alkalinized lidocaine.11,12,18 This report encouraged us to design our study using intra-cuff alkalinized lidocaine in pediatric

patients.Our study showed a significant prolongation of time to spontaneous ventilation and time to extubation in the lidocaine group, which could be explained by induced effective soothing of the tracheal mucosa by released lidocaine across the cuff membrane. Although the incidence of post-extubation coughing in children emerging from general anesthesia has not been previously recorded, our study showed an 88% incidence in the control group, which significantly reduced to 48% in the lidocaine group. These results are in agreement with previous studies conducted on adult population using a small dose13,15-17 or a larger dose11,12 of intra-cuff lidocaine. Because most of the published studies investigated the post-extubation emergence phenomena in pediatric population were conducted on young children (below) the age of 6 years, there is no reported incidence of post-operative sore throat in school age group. The significant reduction in the incidence and severity of postoperative sore throat in our lidocaine group (Table 2) is quite similar to the result of Christopher Crerar et al,19 who reported that intra-cuff alkalinized lidocaine was significantly effective in prevention of postoperative sore throat than direct instillation of

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 21

original article

topical lidocaine on the cuff of ETT in adult patients.The incidence of post-extubation stridor in children intubated with cuffed or un-cuffed tube has been estimated to range from 3.4% to 15.1%.6,20 In our control group, stridor was reported in 16% of patients and insignificantly reduced to 4% in lidocaine group. Although our results are quite comparable to previous studies useing intra-cuff lidocaine11,12,15-17 ( in adults), Baraka et al21, Pernille Leicht et al,22 Sanikop and Sonal Bhat23 reported significant reduction in the incidence of laryngospasm with the use of IV lidocaine 1.5 mg/kg prior to extubation (in young children). This could be explained by the differences in the study designs regarding population, age group, sample size, type of surgery and the route of lidocaine administration.One limitation of our study is that, we did not evaluate ETT emergence phenomena in children below the age of 6 years, who might have higher incidence of these complications. This could be explained by; first, the

fact that most children have their dental treatment during school age, second; the age of six is the minimal age to report the subjective feeling of pain (sore throat), third; traditionally it has been taught that only un-cuffed endotracheal tubes should be used for children under the age of 8 years. The second limitation is that, we applied a safe upper limit cuff pressure of 20 cmH2O, based on the recommendation of Weiss M. et al,6 although there is no published data regarding perfusion pressures of the tracheal mucous membrane or the highest safe ETT cuff pressure in children. This is the goal of another of our ongoing study.

CONCLUSIONIn children with N2O free anesthesia, filling ETT cuff with alkalinized lidocaine significantly reduces the incidence and severity of post-extubation cough, as well as, the postoperative sore-throat, but prolongs time to spontaneous ventilation before extubation.

1. Motoyama EK. Endotracheal intubation. In: Motoyama EK, Davis PJ, Eds. Smith’s anesthesia for infants and children, 5th ed. St Louis, MO: CV Mosby, 1990:269–75.

2. Fisher DM. Anesthesia equipment for pediatrics. In: Gregory GA, editor. Pediatric Anesthesia. 4th ed. Churchill Livingstone; New York: 2001. pp. 207–8.

3. Goel S, Lim SL. The intubation depth marker: the confusion of the black line. Paediatr Anaesth 2003;13:579–83. [Medline]

4. Weiss M, Dullenkopf A, Gerber AC. Microcuff pediatric tracheal tube. A new tracheal tube with a high volume–low pressure cuff for children (German). Anaesthesist 2004;53:73–9 [Medline]

5. Weiss M, Gerber AC, Dullenkopf A. Appropriate placement of intubation depth marks in a new cuffed paediatric tracheal tube. Br J Anaesth 2005;94:80–7. [Medline] [Free Full Text]

6. Weiss M, Dullenkopf A, Fischer J. E, Keller C, Gerber AC. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Aneath 2009;103:867-73. [Medline] [Free Full Text]

7. Dorsey DP, Bowman SM, Klein MB, Archer D, Sharara RS. Perioperative use of cuffed endotracheal tubes is advantageous in young pediatric burn patients. Burns 2010;36:856-60. [Medline] [Free Full Text]

8. Newth CJL, Rachman B, Patel N, et al. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004;144:333–7. [Medline]

9. Roy WL, Lerman J. Laryngospasm in paediatric

anaesthesia. Can J Anaesth 1988;35:93–8. [Medline]

10. Gulhas N, Durmus M, Demirbilek S, Togal T, Ozturk E, Ersoy MO. The use of magnesium to prevent laryngospasm after tonsillectomy and adenoidectomy; a preliminary study. Paediatr Anaesth 2003;13:43–7. [Medline]

11. Fagan C, Frizelle HP, Laffey J, et al. The effects of intracuff lidocaine on endotracheal-tube-induced emergence phenomena after general anesthesia. Anesth Analg 2000;91:201–5. [Medline] [Free Full Text]

12. Altintas F, Bozkurt P, Kaya G, Akkan G. Lidocaine 10% in the endotracheal tube cuff: blood concentrations, haemodynamic and clinical effects. Eur J Anaesthesiol 2000;17:436-42 [Medline]

13. Dollo G, Estebe JP, Le Corre P, et al. Endotracheal tube cuffs filled with lidocaine as a drug delivery system: in vitro and in vivo investigations. Eur J Pharm Sci 2001;13:319-23. [Medline]

14. Khine HH, Corddry DH, Kettrick RG, Martin TM, McCloskey JJ, Rose JB, et al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology 1997 Mar;86(3):627-31. [Medline] [Free Full Text]

15. Estebe JP, Dollo G, Le Corre P, Le Naoures A, Le Verge R, Ecoffey C. Alkalinization of intracuff lidocaine improves endotracheal tube-induced emergence phenomena. Anesth Analg 2002; 94:227-30. [Medline] [Free Full Text]

16. Estebe JP, Delahaye S, Le Corre P, Dollo G , Le Naoures A, Chevanne F , Ecoffey C. Alkalinization of intra-cuff lidocaine and use of

gel lubrication protect against tracheal tube-induced emergence phenomena. Br J Anaesth 2004; 92(3):361-6. [Medline] [Free Full Text]

17. Estebe JP, Gentili M, Le Corre P, et al. Alkalinization of intracuff lidocaine; Efficacy and safety. Anesth Analg 2005;101:1536-41. [Medline] [Free Full Text]

18. Hirota W, Kobayashi W, Igarashi K, et al. Lidocaine added to a tracheostomy tube cuff reduces tube discomfort. Can J Anesth 2000;47:412-4. [Medline]

19. Christopher Crerar, EdwardoWeldon, Jamie Salazar, Kelly Gann, Joseph A. Kelly,Joseph E. Pellegrini. Comparison of 2 laryngeal tracheal anesthesia techniques in reducing emergence phenomena. AANA J 2008 December;76(6): 425-31. [Medline]

20. Deakers TW, Reynolds G, Stretton M, et al. Cuffed endotracheal tubes in pediatric intensive care. J Pediatr 1994;125:57–62. [Medline]

21. Baraka A. Intravenous Lidocaine controls extubation laryngospasm in children. Anesth Analg 1978;57:506–7. [Medline] [Free Full Text]

22. Leicht P, Wisborg T, Chraemmer-Jerrgensen B. Does intravenous lidocaine prevent laryngospasm after extubation in children? Anesth Analg 1985;64:1193–6. [Medline] [Free Full Text]

23. Sanikop CS, Sonal Bhat. Efficacy of intravenous lidocaine in prevention of post extubation laryngospasm in children undergoing cleft palate surgeries. Indian J Anaesth. 2010 Mar-Apr;54(2):132–136. [Medline] [Free Full Text] [Journal Free Full Text]

REFERENCES

22 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

oRIGINAL ARTIcLe

Thoracic epidural for post-thoracotomy and thoracomyoplasty pain: a comparative study of three concentrations of fentanyl with plain ropivacaineAjay Kr Chaudhary*, Dinesh Singh**, Jai Shri Bogra***, Sulekha Saxena****,Girish Chandra*****, Shashi Bhusan*****, Prithvi Kr Singh******

*Assistant Professor; **Associate Professor; ***Professor and Head; ****MD Student; ******Professor; *****PhD Fellow

Department of Anesthesiology, K.G.M. College, Lucknow (UP), (India) 226003

Correspondence: Dr. Sulekha Saxena, Department of Anesthesiology, King George’s Medical University Lucknow (UP), (India) 226003; dr.sulekha2008@rediffmail.com

ABSTRACTAim: Optimum pain relief after thoracotomy is essential to reduce atelectasis and postoperative pneumonias. The aim of this prospective, double blind, randomised controlled trial was to compare the analgesic and adverse effects of three concentrations of fentanyl with 0.2% ropivacaine in thoracic epidural in patients undergoing thoracotomy andthora-comyolpasty.

Methodology: After getting approval from Ethical Committee, this study was performed in 60 patients of either sex, aged 18-60 years, American Society of Anaesthesiology (ASA) grade I to III. Informed consent was taken from all of the patients, who were recruited and divided into three groups of 20 patients in each group. Patients scheduled for elective thoracotomy surgery were enrolled in the study. Patients with preexisting motor and sensory deficit, addicted to hypnosedative drugs, on chronic opioid or analgesic therapy, sensitive to local anaesthetic or study medication, or having contraindications to regional anesthesia were excluded from this study. In patients, with whom communication difficulties prevented reliable assessment, were also excluded.

Patients received either 2.5µg/ml (Group I), 5.0µg/ml (Group II) or 7.5µg/ml of fentanyl (Group III) respectively, with ropivacaine 0.2% via thoracic epidural. Postoperatively, pain at rest, on coughing and with ambulation was assessed using a visual analogue scale (VAS) and observer verbal ranking score (OVRS) at 2, 6, 12 and 24 hours. Sedation scores were also noted. Adverse effects were simultaneously assessed.

Results: There was no significant difference in the baseline characteristics between the three groups. The number of patients with episodes of unsatisfactory pain relief, i.e. a VAS scores >40 and OVRS >2, at each of the four assessments postoperatively, was higher in Group I than with Group II or Group III (p < 0.05). In Group III, four (20%) patients had a sedation score >3 compared with one (5%) in Group II. No patient in Group I had a sedation score >3 (p < 0.05). In addition, all patients experienced pruritus in Group I compared with 10% and 5% in Group II and Group I respectively. 30% of the patients had emetic symptoms in Group III, compared to 20% and 5% in Group II and Group I respectively (p < 05).

Conclusion: We conclude that a thoracic epidural bolus of 10 ml ropivacaine 0.2% with fentanyl 5.0 μg/ml provides the optimal balance between pain relief and sedation.

Keywords: Thoracic epidural; Pain; Fentanyl; Ropivacaine; Thoracotomy; Thoracomyolpasty; Pain relief; Visual ana-logue scale; VAS; Observer verbal ranking score; OVRS

Citation: Chaudhary AK, Singh D, Bogra JS, Saxena S, Chandra G, Bhusan S, Singh PK. Thoracic epidural for post-thoracotomy and thoracomyoplasty pain: a comparative study of three concentrations of fentanyl with plain ropivacaine. Anaesth Pain & Intensive Care 2013;17(1):22-27

INTRODUCTIONAfter thoracotomy, the sources of perceived pain are numerous, which are surgical incision, disruption of ribs and intercostal nerves, inflammation of chest wall structures adjacent to the incision, incision or crushing of pulmonary parenchyma or pleura, stretching of

shoulder joint and placement of thoracostomy drainage tubes.1 Optimum pain relief is essential if the incidence of atelectasis and postoperative pneumonias are to be reduced.2,3 Patients must not only be pain free at rest but must also be able to breathe deeply, cough effectively and comply with postoperative physiotherapy. Additional challenges faced by clinicians in these

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 23

original article

patients include old age, malnourishment, and frequent co-existing cardio-respiratory diseases. A number of analgesic techniques have been used to achieve pain relief.3,4 Ropivacaine is an amino-amide local anaesthetic and a less toxic homolog of bupivacaine. It can produce excellent analgesia and result in less intense motor block than bupivacaine when given by epidural infusion.5

However, the incidence of hypotension with 0.5% ropivacaine is high and lower concentrations when used alone are likely to be less effective.6,7 Fentanyl is a short-acting lipophilic opioid analgesic developed fentanyl by assaying analogues of the structurally related drug pethidine for opioid activity. Epidural opioids have also been used after thoracotomy. There has been much interest in attempts to improve the quality of epidural opioid analgesia by the addition of a low concentration of local anesthetic to reduce the incidence of side-effects.7, 8 The important clinical question is what concentration of fentanyl in ropivacaine 0.2% will provide effective analgesia with minimal adverse effects after invasive thoracic surgery. Therefore, this prospective, randomized, double blind study was designed to compare the analgesic and adverse effects of three different concentrations of thoracic epidural fentanyl with 0.2% ropivacaine in patients undergoing thoracotomy and thoracomyolpasty.

METHODOLOGYAfter obtaining institutional ethical committee approval and written informed consent, 60 patients undergoing thoracotomies, aged 18–60 years, of either sex admitted in the Surgical Department, King George’s Medical University, Lucknow, between August 2011 to July 2012, belonging to American Society of Anesthesiologists (ASA) physical status I-III were recruited in the study and divided into three groups of 20 patients in each group. Exclusion criteria were patient refusal, any contraindication for epidural anesthesia, preexisting motor and sensory deficit, sensitive to local anaesthetic, patients with previous thoracic surgeries or known drug allergy.Patients were randomized to receive one of three epidural solutions using a computer-generated table of random numbers. Group I: Patients received 10 ml solution of 0.2% ropivacaine with 2.5μg/ml fentanyl.Group II: Patients received 10 ml solution of 0.2% ropivacaine with 5μg/ml fentanyl.Group III: Patients received 10 ml solution of 0.2% ropivacaine with 7.5µg/ml fentanyl.The study solution was provided in 50 ml syringes

labelled with the patient’s name and trial code. Thus, patients as well as staff in theatre and in the ward were blinded to the study solution. On arrival of the patient in the operating room, a peripheral venous line was secured and IV infusion was established. Oxygen supplementation was given to all the patients using Venturi mask. FEV1, FVC and PEFR were measured pre-operatively and post-operatively at 2, 6, 12 and 24 hours. All patients received a standardized anesthetic with midazolam 0.05 mg/kg and fentanyl 1 μg/kg IV. After pre-oxygenation for 5 min, general anesthesia was induced with propofol 2–3 mg/kg IV. Neuromuscular block was achieved with atracurium 0.5mg/kg IV and trachea was intubated using an appropriate sized cuffed double-lumen endobronchial tube. Correct tube position was confirmed with help of stethoscope and EtCO2 and anesthesia was maintained with with halothane 0.5–1% in N2O and oxygen 50% each. Thoracic epidural catheter was inserted under the general anesthesia at T4/5 or T5/6 inter-space at this time and the study solution was administered at 0.1 ml/kg/h after a loading dose of 0.1 ml/kg using syringe pump, prior to surgery.Surgical incision was allowed after 10 min of epidural bolus. At any time during surgery, if the mean arterial pressure and heart rate increased to ≥25% of baseline, supplemental analgesic in the form of fentanyl 1μg/kg IV was given. Any episode of hypotension (systolic arterial pressure <90 mmHg) excluding surgical blood loss was treated with incremental doses of ephedrine, and bradycardia (heart rate < 50/min) was treated with atropine. On completion of surgery the patients were reversed with neostigmine 2.5 mg and glycopyrrolate 500 mcg. Patients were then managed in a post-anesthesia care unit (PACU) for 24 hours. Analgesia was assessed at 2, 6, 12 and 24 hours using a visual analogue scale (VAS) (0 = no pain; 100 = worst pain imaginable) both at rest, and with cough and ambulation, after extubation. At the same time, pain was assessed using a four-point observer verbal ranking scale (OVRS) for pain9 (Table 1).

Table 1: Observer verbal ranking scale for pain8

Pain score Pain experience

0 No pain; pain not restricting any activity e.g. cough, turning on the side

1Mild pain, able to take maximal deep breath but movement and coughing slightly restricted by pain; physiotherapy effective

2 Moderate pain, needs help to move onto side; cough and deep breathing restricted by pain; physiotherapy effective

3 Severe pain; pain making turning onto side impossible and/or patient refuses to try

24 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

thoracic epidural for post-thoracotomy and thoracomyoplasty pain

Sedation scores were also judged by the observer (0= awake; 1 = mild sedation; 2 = moderate sedation, easily arousable; 3 = heavily sedated difficult to rouse; 4 = over sedated, unrousable).9

At a VAS score of >40 and OVRS >2 supplemental analgesic was given in the form of epidural bolus of 0.1 ml/kg solution. Any episodes of nausea and/or vomiting, pruritus, urinary retention, sedation and respiratory depression were recorded at the same time as pain scores and treated accordingly.

All statistical analyses were performed using SPSS for windows vs. 15.0. Continuous variables were tested for normal distribution by the Kolmogorov–Smirnov test. Parametric data was compared using analysis of variance (ANOVA) within group comparisons at different time intervals assessed by using paired t-test. All the categorical data was compared by using chi square test. A sample size of 20 patients in each group was needed to detect an intergroup difference of at least 20% ( = 0.01, two-sided, power = 95%) with two sample t-test.10 Data were collected by a blinded observer and are presented as mean ± SD or N (%). A p-value of < 0.05 was taken to be significant.

RESULTSThe three groups were comparable in age, weight, height, sex, ASA classification, lung function, duration of surgery and other variables recorded before operation (p>0.05) (Table 2). In the 2.5μg/ml fentanyl and 5μg/ml fentanyl groups 80% and 30% patients, respectively, required supplementary fentanyl in the intraoperative period while none of the patients in the 7.5µg/ml fentanyl group required such (p<0.05). The total dose of fentanyl required was also significantly higher in the group I than in the group II or III (p <0.05) (Table 3). Intraoperatively, 80%, 30% and 25% of patients of Group I, Group II and III respectively, showed VAS score for pain ≥40 (Figure 1).

Table 2: Demographic characteristics and pre-operative variables of the three study groups

Parameter Group 1 Group 2 Group 3

Age (year) 45 ± 8 42 ± 18 43 ± 16

Sex (M:F) 11:9 9:11 10:10

Height (cm) 165 ± 15 170 ±15 168 ±18

Weight (kg) 68 ± 12 65 ± 14 70 ± 16

Duration of surgery (min) 145 ± 35 150 ± 30 148 ± 36

ASA (I:II:III) 4:10:6 3:10:7 5:9:6

RR (per min) 22 ± 4 23 ± 4 22 ± 3

HR (per min) 82 ± 12 86 ± 14 80 ± 12

SAP (mmHg) 150 ± 28 142 ± 32 146 ± 30

FEV1 (forced expiratory volume in one second)(lit)

1.9 ± 0.3 2.0 ± 0.4 1.9 ± 0.2

FVC (forced vital capacity)(lit) 2.4 ± 0.6 2.5 ± 0.3 2.4 ± 0.4

REFR (peak expiratory flow rate)(lit/min)

390 ± 110 380 ± 120 395 ± 115

Table 3: Intra-operative supplementary fentanyl requirement

Group I (n = 20)

Group II (n = 20)

Group III (n = 20)

Number of patients requiring supplementary fentanyl

16 (80%) 6 (30%)* 0*+

Total dose of fentanyl (Mean ± SD) (in µg) 76 ± 22 42 ± 18* 0*

* p < 0.05 (I vs II and I vs III)

+ p < 0.05 (II vs III)

None of the patients in the Group I had sedation (score ≥3) while in the Group II and III, 20% and 50% patients, respectively, had sedation (p < 0.05). Pruritus did not differ statistically among the groups though significantly higher incidence (30%)was observed in Group III (p<0.05). None of the patients in any of the groups complained of numbness or limb weakness. Incidence of hypotension and nausea in each group was statistically comparable (p>0.05). One patient in each group had bradycardia that required treatment (Table 4).FEV1, FVC and PEFR were all reduced to 40–50% of their preoperative values throughout the study period in all three groups. Nausea and PaCO2 did not differ between the three groups.

DISCUSSIONPain in thoracotomy arises as a result of severe chest wall trauma which includes fractured ribs and Figure 1: Total VAS score (%)

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 25

original article

damaged peripheral nerves and central nervous system hypersensitivity. Thoracic pain cannot be controlled by chest wall immobilized; if secretions are to be cleaned, it must remain in constant motion, indeed vigorous motion. Incidence of pneumonia and atelectasis is to be reduced with pain relief after thoracotomy, thereby patients can take deep breath, cough effectively.Our results show that significantly (P<0.01) more patients receiving epidural fentanyl 2.5 μg/ml with ropivacaine 0.2% had VAS≥40 compared with those who received fentanyl 5 or 7.5 µg/ml. In addition, there was a tendency for a higher incidence of sedation scores >3 and of pruritus, in Group III compared with Groups II and I. No significant difference in hypotension and bradycardia between the three groups was noted.Our results concur with those of a randomized controlled trial of thoracic epidural fentanyl 2.5, 5, 10 and 20 μg/ml with no local anaesthetic.11 It was shown that there was a concentration-dependent reduction in pain intensity in patients undergoing thoracotomy for lung resection. With fentanyl 2.5 μg/ml, there was a significant decrease in proportion of patients with >50% reduction in pain scores, compared with higher concentrations (fentanyl 5, 10 and 20 μg/ml). In another study comparing thoracic epidural fentanyl in doses of 1, 2 and 4 μg/ml in ropivacaine 0.2% for patients undergoing major abdominal surgery, it was shown that pain intensity was significantly greater in patients receiving fentanyl 1 to 2 μg/ml than those having fentanyl 4 μg/ml.12

Epidural local anesthetic agents have an established role in analgesia during thoracic surgery. Opioids administered via the epidural route have been found to be superior in terms of analgesia, side-effects,

length of stay and postoperative complications after thoracotomy.13 Hypotension was the most common side-effect with the use of the above and ropivacaine 0.5% in thoracic epidural, occurring in 80% of cases of patients in whom satisfactory analgesia was achieved.7 The high incidence of hypotension with ropivacaine can be attributed to sympathetic block.14 Although epidural administration of opioids does not result in sympathetic block15 hypotension has been observed with an epidural fentanyl,16 which could be related to systemic uptake from epidural space. In view of these findings and to avoid hypotension associated with either a high concentration of ropivacaine or a high dose of fentanyl, we used a continuous infusion (2.5 µg/ml, 5 µg/ml and 7.5µg/ml) rather than bolus high doses of fentanyl in a lower concentration of ropivacaine (0.2%).On demand patient-controlled epidural analgesia after thoracotomy and upper abdominal surgery using fentanyl 1 μg/ml with ropivacaine 0.125% assessed in a previous study6 did not significantly reduce the amount of supplementary fentanyl required, the pain scores or the side effects. Taking this into consideration we chose to use three different concentrations of fentanyl in 0.2% ropivacaine in our study. It has been demonstrated that epidural fentanyl contributes significantly to the analgesia component of balanced anesthetic during lung surgery15. Our result showed that epidural fentanyl with ropivacaine produces analgesia and is concentration dependent. The duration and intensity of pain relief were increased when a higher concentration of the drug was given, up to a maximum concentration of 7.5µg/ml. More patients receiving epidural fentanyl 2.5μg/ml in ropivacaine 0.2% had pain (VAS ≥40) compared with those who received fentanyl 5.0µg/ml or 7.5µg/ml in ropivacaine 0.2% (Figure 1). Preoperative and postoperative thoracic epidural analgesia techniques have been assessed on post-thoracotomy pain: preoperative epidural analgesia was found to be an appropriate method and was more effective in preventing acute post-thoracotomy pain17.Taking this into consideration; we administered perioperative thoracic epidural analgesia in our study. Different epidural analgesics and their effects on pulmonary function have been compared in the past9. Throughout the postoperative period, reductions of up to 70% of the preoperative values (FEV1, FVC and PEFR) were noticed in all the study groups that mean with the different concentrations of fentanyl used in our study, no difference was found among the groups with regard to pulmonary functions.

Epidural opioids are associated with dose-dependent adverse effects of sedation, pruritus, nausea and

Table 4: Comparison of adverse effects in three groups. Data expressed as N(%)

Adverse effects Group I (n-20)

Group II (n-20)

Group III (n-20)

Sedation (≥ 3) score 0(0) 1(5) 4(20)

Pruritus 1(5) 2(10) 6(30)

Emetic symptoms 1(5) 4(20) 6(30)

Numbness 0(0) 0(0) 0(0)

Limb weakness 0(0) 0(0) 0(0)

Hypotention 1(5) 1(5) 2(10)

bradycardia 1(5) 1(5) 1(5)

Shoulder pain 0(0) 0(0) 0(0)

26 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

thoracic epidural for post-thoracotomy and thoracomyoplasty pain

respiratory depression.18 In this regard, in our study a concentration of 5μg/ml fentanyl was found to be optimum. On the other hand, lower concentrations of epidural fentanyl (2.5μg/ml) do not provide high quality analgesia following thoracic surgery. In patients who receive insufficient analgesia, an alternative method of increasing the concentration of epidural opioids is to consider an additional drug, i.e. clonidine 19.

In our study there appeared to be an increased incidence of pruritus (30%) in patients receiving epidural fentanyl 7.5 µg/ml. Our findings are in accordance with those of the previous report.20

This trend is consistent with a RCT in which the incidence of pruritus increased from 17% at fentanyl 10 μg/ml, to 36% at fentanyl 20 μg/ml11. In other studies of lower fentanyl concentrations, this concentration dependent effect was also demonstrable. For instance, the incidence of pruritus was 23%, 8%, 4% and 4% in obstetric patients receiving epidural fentanyl of concentrations 4, 3, 2 and 1 μg/ml, respectively.21 Furthermore, in a RCT of 244 patients undergoing major abdominal surgery, thoracic epidural fentanyl 4 µg/ml was associated with a significantly (P<0.02) higher incidence of pruritus than fentanyl1 μg/ml to 2 μg/ml.12

Our study in which there was a tendency to increased sedation in 20% of patients in the 7.5 µg/ml fentanyl group had a sedation score ≥3, concurs with a study by Welchew and colleagues.11 He showed that increased sedation occurred at fentanyl 10, 20 μg/ml but not at fentanyl 2.5 μg/ml. In two other RCTs of patients receiving thoracic epidural fentanyl 1, 2 and 4 μg/ml in ropivacaine 0.2%, sedation scores were low and no significant difference in sedation was detected 12, 21.

In our study a significant difference in nausea and vomiting was found between the three treatment groups. The patients in the Group III, 30% experienced nausea and vomiting, while in Group I 5% and Group II 20%. This result differs from results obtained in an earlier study.22 This difference may be because our patients received general anesthesia with epidural analgesia, while in the other studies mentioned the patients received only epidural anesthesia.In our study, assessments were made in the first 24 h postoperatively, and so our results are applicable to this period. After thoracotomy for lung resection, patients may have an epidural in situ for 5 days. Analgesic requirements are expected to be much reduced on day 3 compared with the immediate postoperative period. Thus if this study was extended beyond the first 24 h, then it is likely that we would have recorded a progressive reduction in opioid consumption in all treatment groups. By day 3, opioid consumption would be low; any possible differences in pain scores and opioid related adverse effects would not be detectable between groups.

CONCLUSIONIn conclusion, our study has shown that thoracic epidural fentanyl 5 µg/ml or 7.5 µg/ml are associated with superior analgesia after thoracotomy compared with fentanyl 2.5 μg/ml, when used in conjunction with ropivacaine 0.2% in the immediate postoperative period. However, the use of fentanyl 7.5 µg/ml is associated with excessive sedation and pruritus. Therefore, epidural fentanyl 5 μg/ml in ropivacaine 0.2% would appear to provide the optimal balance between pain relief and adverse effects following thoracic surgery.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 27

original article

1. Sanjay OP, Kadam VR, Menezes J, Prashanth P, Tauro DI. Thoracic epidural infusions for post thoracotomy pain relief: a clinical study to compare the efficacy of fentanyl –bupivicaine mixtures versus fentanyl alone. Ind J Thorac Cardiovasc Surg, 2003; 19:113-118.

2. Gottschalk A, Cohen S, Yang S, Ochroch EA. Preventing and treating pain after thoracic surgery. Anesthesiology 2006; 104: 594–600

3. Ng A, Swanevelder J. Pain relief after thoracotomy: is epidural analgesia the optimal technique? British Journal of Anesthesia 2007; 98 (2): 159–62.

4. Chia YY, Wei RJ, Chang HC, Liu K.Optimal duration of urinary catheterization after thoracotomy in patients under postoperative patient-controlled epidural analgesia. Acta Anaesthesiol Taiwan 2009;47(4):173-9.

5. Korula S, George GM, Ipe S, Abraham SP. Epidural anesthesia and post-operative analgesia for bilateral inguinal mesh hernioplasty: Comparison of quipotent doses of ropivacaine and bupivacaine. Saudi J Anaesth 2011; 5(3): 277–281.

6. Shorrab NA, Abdel-Mageed, Siam UA & Metawea AA: Intermittent Thoracic Epidural Administration of Ropivacaine-Fentanyl versus Bupivacaine-Fentanyl after Thoracotomy. The Internet Journal of Anesthesiology 2007;13:1.

7. Sakai T, Tomiyasu S, Sumikawa K. Epidural ropivacaine infusion for the treatment of pain following axillary muscle-sparing thoracotomy: a dose-evaluation study. Journal of Anesthesia 2007; 21(3): 320-324.

8. Singh V, Kanshal , D Yadav N, Gupta R, Kumar S. Thoracic epidural for post-thoracotomy pain: a comparison of three concentrations of

sufentanil in bupivacaine. SAJAA 2009; 15(2): 16-21.

9. Tan CNH, Guha A, Scawn ND, Pennefather, SH, Russel GN. Optimal concentration of epidural fentanyl in bupivacaine 0.1% after thoractomy. Br J Anaesth 2004;92:670-4.

10. Murphy KR and Myors B. Statistical Power Analysis: A Simple and General Model for Traditional and Modern Hypothesis Tests 2nd Edn (Lawrence Erlbaum Associates, Mahwah, NJ). 2004.

11. Gísli Vigfússon, Gísli H. Sigurðsson, Epidural pain management after open lateral thoracotomy: Female patients have better pain relief and need smaller amounts of analgesics than males, Scandinavian Journal of Pain 2012; 3(2): 108-111.

12. Scott D, Blake D, Buckland M, Etches R, et al. A comparison of epidural ropivacaine alone and in combination with 1, 2, and 4 µg/ml fentanyl for 72 hrs of postoperative analgesia after major abdominal surgery. Anesth Analg 1999; 88:857-64.

13. Debrecini G, Molnar Z, Szelig L, Molnar TF. Continuous epidural or intercostal analgesia following thoracotomy: a prospective randomised double-blind clinical trial. Acta Anaesthesiol Scand 2003;47:1091–5.

14. Wattwil M, Sundberg A, Arvill A, Lennquist C. Circulatory changes during high thoracic epidural anesthesia – influence of sympathetic block and of systemic effect of the local anesthetic. Acta Anesthesiol Scand 1985;29:849-55.

15. Paech MJ, Pavy TJG, Orlikowski CEP, et al. Post operative intraspinal opioid analgesia after caesarean section; a randomised comparison

of subarachnoid morphine and epidural pethedine. Int J Obstet Anaesth. 2009;9:238-245

16. Haak-van der Lely F, van Kleef JW, Gesink-van der Veer BJ, Burm AG, Bovill JG. Efficacy of epidurally administered sufentanil versus bupivacaine during thoracic surgery. A randomized placebo-controlled double-blind study. Anesthesia 1994;49:116-8.

17. Yegin A, Erdogan A, Kayacan N, Karsli B. Early postoperative pain management after thoracic surgery; pre and post operative versus post operative epidural analgesia: a randomized study. Eur J Cardiothorac Surg 2003;24:420-4.

18. Chaney MA. Side effects of intrathecal and epidural opioids. Can J Anaesth 1995;42:891-903..

19. Curatolo M, Schnider T, Petersen Flex S et al. A direct search procedure to optimize combinations of epidural bupivacaine, fentanyl and clonidine for postoperative analgesia. Anesthesiology 2000;92:325-37.

20. Lyons G, Columb M, Hawthorne L, Dresner M. Extradural pain relief in labour: bupivacaine sparing by extradural fentanyl is dose dependent. Br J Anaesth 1997;78:493-7.

21. Scott, D, Blake D, Buckland M et al. A comparison of epidural ropivacaine alone and in combination with 1, 2 and 4 g/ml fentanyl for 72 hrs of postoperative analgesia after major abdominal surgery. Anesth Analg 1995;81:973-81.

22. Liu SS, Moore JM, Luo AM, Traufman W et al. Comparison of three solutions of ropivacaine/fentanyl for postoperative patient controlled epidural analgesia. Anesthesiology 1999;90:727-32.

REFERENCES

sHARe yoUR sToRy

Dear Readers;Thank you very much for being associated with your own journal. Anaesthesia, Pain & Intensive Care is being published and distributed on a non-profit basis. We invite you to contribute in this scientific, educa-tional venture in a way which suits you the best. We invite you to contribute in a variety of ways. We pub-lish editorials, original articles, case reports and review articles. ‘Cliniquiz®’ is a scenario based, MCQ type clinical quiz, usually consisting of ten MCQ’s. ‘Clinipics®’ offers an opportunity to our esteemed readers to share their unusual snap shots taken during the course of their clinical practice. The pictures must be useful and of academic import for the readers. We prefer pictures relevant to the practice of anesthesiology, pain management, intensive care or resuscitation. ‘My Most Memorable Patient®’ and ‘My Most Unforgettable Experience®’ comprise of short stories from day to day clinical practice, which once touched your heart and you want to share these with your friends on this forum.

28 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

oRIGINAL ARTIcLe

‘Maximum surgical Blood order schedule’ in a newly set-up tertiary care hospitalR. Thabah, MBBS, MD*1, L. T. Sailo, MBBS, DA*2, J. Bardoloi, MBBS, MD*3, M. Lanleila, MMBS, MD*4, N. M. Lyngdoh, MBBS, MD**, M. Yunus, MBBS, MD***, P. Bhattacharyya, MBBS, MD, PDCC****

*Ex-Senior Resident; **Assistant Professor; ***Associate Professor; ****Professor & HODDepartment of Anesthesiology & Intensive Care, NEIGRIHMS, Shillong, Meghalaya (India) 1Consultant Intensives, Super Care Hospital, Shillong, Meghalaya (India)2Postgraduate Trainee, Department of Anesthesiology, Regional Institute of Medical Sciences (RIMS), Imphal , Manipur (India)3Consultant Anesthesiologist & Intensivist, Woodland Hospital, Shillong, Meghalaya (India)4Specialist Anesthesia, Composite Hospital, BSF Shillong, Meghalaya (India)

Correspondence: Dr. M. YunusMBBS, MD, Additional Professor, Department of Anesthesiology & Critical Care, Faculty In-charge of Emergency Medicine & Casualty Services, NEIGRIHMS, Mawdiangdiang, Shillong, Meghalaya (India); Phone: 91-364-2538026 & 91-364-2538009 (O) 91-364-2538049(R); Cell: 91-9436706438, 91-9774334284; Email: drmdyunus@hotmail.com , drmdyunusrizvi@gmail.com; Web: http://neigrihms.nic.in/

ABSTRACT Aim: Limited availability and supply necessitates the rational use of blood and blood products and avoidance of unnecessary transfusion. A study was carried out in our tertiary care hospital over a period of two years to determine the usage of blood during different surgical procedures. Therefore, the ratio of units cross-matched to units transfused and transfusion probability were calculated. In this study, besides identifying the cases in which blood wastage was present, different factors and circumstances which affect Maximum Surgical Blood Order Schedule (MSBOS) were also noted.Methodology: After ethical committee approval and informed consent, 305 patients, ASA I and II, were inducted who were scheduled for elective surgical procedures. Parameters recorded were age, sex, hemoglobin, hematocrit, number of blood units crossmatched, duration of surgery, blood loss, type of anesthesia, cross-match to transfusion ratio (C/T), transfusion probability and transfusion index.Results: Among 305 patients, in the Obstetrics and Gynecology group the C/T ratio was 2.4 in cesarean section, in Surgery group it was maximum in open cholecystectomy (11), in the Urology group it was 6 in carcinoma bladder, in the spine surgeries it was 2.6 and in PDA ligation it was 7. Conclusion: By a team approach involving the surgeon, anesthesiologist and hematologist we can reduce the number and pattern of ordering blood for various surgeries.Key words: Maximum Surgical Blood Order Schedule; MSBOS; Blood bank; Cross-matching; Cross-match to transfusion ratio (C/T ratio); Transfusion probability; Transfusion index.

Citation: Thabah R, Sailo LT, Bardoloi J, Lanleila M, Lyngdoh NM, Yunus M, Bhattacharyya P. ‘Maximum Surgical Blood Order Schedule’ in a newly set-up tertiary care hospital. Anaesth Pain & Intensive Care 2013;17(1):28-32

INTRODUCTIONThe Maximum Surgical Blood Order Schedule (MSBOS) is a table of elective surgical procedures which lists the number of units of blood routinely cross-matched pre-operatively. However, they are intended only as a guide to the ordering of blood and blood products and are interpreted according to individual circumstances, including the clinical condition of the patients. In 1970’s, MSBOS was proposed by Friedman et al so as to reduce the number of units of blood which were wasted and not

transfused during the surgical procedures. It also reduces the consumption of blood bank resources and the time. Despite its benefit, the MSBOS still recommends that for patients with a likelihood of blood transfusion, the number of units cross-matched be twice the median requirement for that surgical procedure and the cross-matched to transfusion ratio (C:T) is 2:1.1

The main aim of our study was to improve the efficacy of ordering and utilization of blood and blood products by formulation of MSBOS for common procedures, where

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 29

original article

there is no ready availability of blood and the process of cross-matching, grouping, screening still takes 45-60 min instead of the electronic (or computer based) cross-matching, which reduce unnecessary cross-matching and provide compatible units within few minutes rather than hours.

METHODOLOGYThis study was conducted over a period of 2 years from December 2006 to December 2008 and included three hundred and five patients, ASA Grade I & II, who were scheduled for elective surgical procedures in our tertiary care hospital. The patients were grouped under specific surgical procedures. We wished to exclude patient related co-morbid conditions so patients falling in ASA grade III or IV were excluded. The pre-operative data included patient’s age, sex, weight, hemoglobin, hematocrit and the number of blood units cross-matched. The intra-operative data included the duration of surgery, the type of anesthetic procedure, blood loss which was calculated subjectively by a visual method of blood absorbed in small gauge (20-30 ml/chest swab) and large pad (80-100 ml/abdominal sponge) and volumetric method using suction with calibrated containers. At the end of the surgery, the CT ratio, transfusion probability and transfusion index were calculated.(1) The formula for cross-matched to transfusion: C:T ratio = No. of units cross-matched No. of units transfused

A ratio of > 2 is considered indicative of significant blood wastage.

(2) The formula for transfusion probability:

Transfusion probability % = No. of patients transfused x 100 No. of patients cross-matched

A value of < 30 was considered indicative of significant blood wastage.

(3) The formula for Transfusion index:

Transfusion index = No. of units transfused No. of patients cross-matched

A value of < 0.5 signifies no need for cross-match.

RESULTS This study, which included three hundred and five patients, was done during the period when the blood bank was located at a distance away from the hospital and it took an hour or so for the blood units to reach the operating rooms. The study results have been grouped into five tables; each table representing the number of cases for a different type of surgical discipline, e.g. Obstetrics and Gynecology, General Surgery, Urology, Orthopedics and Cardiothoracic Surgery.

Obstetrics and Gynecology:

In this group there were a total of 66 cases, the highest number being for cesarean section, followed by total abdominal hysterectomy; suction evacuation, ectopic pregnancy and uterovesical fistula being the least common.

In the Table 1, the CT ratio for cesarean section was 2.4, for vaginal hysterectomy 6.5, and for laparotomy for ovarian tumour/cyst it was 6. The CT ratio for other surgeries was ≤2 which was within the MSBOS criteria.

General Surgery:In the various general surgical procedures, the most common were cholecystectomy, thyroidectomy and esophagectomy; with a total of 119 cases studied. Table 2 shows general surgery cases. The CT ratio for open cholecystectomies was 11, for thyroidectomy 2.3, for modified radical mastectomy (MRM) 2.1, for Whipple’s procedure 4.5, common bile duct (CBD) exploration 3.5, for pseudopancreatic cyst and

Table 1: Obstetrics and gynecology cases

S. No Surgical procedure No. of cases

X- matched Transfused C/TRatio

Transfusion Probability

TransfusionIndexUnits Pts Units Pts

1 LSCS 22 22 18 9 4 2.4 22.2% 0.5

2 Total Abdominal Hysterectomy 16 24 14 22 10 1.09 41.6% 1.5

3 Ectopic Pregnancy 4 8 4 5 4 1.6 100% 1.25

4 Vaginal Hysterectomy 8 13 8 2 2 6.5 25% 0.25

5 Suction Evacuation 4 7 4 8 4 0.8 100% 2

6 Laparotomy for Ovarian tumor/cyst 8 12 8 2 2 6 25% 0.25

7 Uterovesical fistula 4 8 4 4 4 2 100% 0.5

30 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

‘maximum surgical blood order schedule’

Table 2: Distribution of surgical cases

S. No. Surgical procedure No. of cases

X-matched Transfused C/T ratio

Transfusion Probability

Transfusion IndexUnits Pts Units Pts

1 Open Cholecystectomy 25 11 7 1 1 11 14.28% 0.142 Esophagectomy 10 21 10 11 8 1.9 80% 1.13 Buccal mucosa wide excision 4 2 2 1 1 2 0.5% 0.54 Thyroidectomy 12 14 11 6 6 2.33 54.5% 0.55 Capillary hemangioma 4 4 4 4 4 1 100% 16 Hemorrhoids 4 0 0 0 0 0 0% 07 Exploratory laparotomy 8 8 7 4 4 2 57.1% 0.578 Colostomy closure 2 1 1 0 0 ∞ 0% 09 Gastrectomy 6 10 6 8 3 1.6 50% 1.3

10 Hydrocelectomy & hernia 6 2 2 2 2 1 50% 111 MRM 8 15 8 7 4 2.1 50% 0.812 Wide excision of scalp ulcer 1 3 1 2 1 1.5 100% 213 Gastro-jejunostomy 4 8 9 2 2 4 22.2% 0.214 VATS 2 4 2 2 1 2 50% 0.515 Whipple’s procedure 3 9 3 2 1 4.5 33.33% 0.6616 Perianal fistula 2 0 0 0 0 0 0% 017 Parotidectomy 2 1 1 1 1 1 100% 118 Appendicectomy 9 0 0 0 0 0 0% 019 CBD exploration 5 7 4 2 1 3.5 25% 0.2820 Pseudopancreatic cyst surg 3 4 3 1 1 4 33% 0.33

Table 3: Distribution of various urology cases

S. No. Surgical procedure No. of cases

X-matched Transfused C/T ratio

Transfusion Probability

Transfusion IndexUnits Pts Units Pts

1 Nephrectomy 10 22 10 12 8 1.8 80% 1.22 VVF Repair 4 4 4 2 2 2 50% 0.53 TUR (BT) for Ca. 6 12 6 2 2 6 33.3% 0.334 TUR(P) for BPH 4 8 4 0 4 ∞ 100% 05 Pyelolithotomy 10 21 10 2 2 10.5 20% 0.26 Ureterolithotomy 3 7 3 1 1 7 3.33% 0.337 Pyeloplasty 4 8 4 8 4 1.0 100% 28 Urethroplasty 3 3 2 2 2 1.5 100% 1

Table 4: Distribution of orthopedic cases

S. No Surgical procedure No. of cases

X-match TransfusionC/T Transfusion

ProbabilityTransfusion

IndexUnits Pts Units Pts1 Tendon Repair 5 0 0 0 0 0 0% 02 Ankle Orthrodesis 6 6 5 1 1 3 20% 0.23 Drainage of Ch. Osteomyelitis 3 2 2 0 0 ∞ 0% 04 THR 3 9 3 5 3 1.8 100% 1.666 Debridement SSG 3 1 1 1 1 1 100% 1

7 Debulking of giant cell tumor/ bone grafting and reconstruction 4 12 4 12 4 1 100% 3

8 Therapeutic Arthroscopy 4 0 0 0 0 0 0% 09 ORIF, Femur 7 14 7 4 4 3.5 57.1% 0.5710 ORIF, Shoulder 6 6 6 3 3 0 .5 50% 0.511 ORIF, tibia and fibula 4 2 2 2 2 2 100 % 112 Spine Surgery 6 8 5 3 3 2.6 60% 0.613 Stump revision post amputation 2 2 0 0 0 ∞ 0% 014 ORIF radius + ulna 2 1 1 1 1 1 100% 115 Wound debridement - crush inj 4 2 2 1 1 2 50% 0.5

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 31

original article

gastrojejunostomy it was 4.The CT ratio for other surgeries was ≤2 which was within the MSBOS criteria.Urology:Among the various urology cases, the most common procedures were nephrectomy and pylolithotomy, with a total number of cases being 44. In, Table 3, urology cases, the CT ratio for TUR(BT) for Ca. urinary bladder was 6, pyelolithotomy 10.5 and for ureterolithotomy 7 respectively. The CT ratio for other surgeries was ≤2 which was within the MSBOS criteria.Orthopedics

In the orthopedic cases open reduction and internal fixation (ORIF) for fracture femur was the most common procedure, followed by spinal surgeries; with a total of 43 cases. In Table 4 (orthopedic cases), the CT ratio for ankle arthrodesis was 3, ORIF of femur was 3.5 and spine surgeries 2.6, respectively.The CT ratio for other surgeries was ≤2 which was within the MSBOS criteria.Cardiothoracic Surgery:

In this specialty the most common procedure was patent ductus arteriosus (PDA) ligation followed by decortication with a total of 17 cases.In Table 5 [cardiac and thoracovascular surgery (CTVS) cases], the CT ratio for patent ductus arteriosis (PDA) 7, sternotomy 4, and other cases ≤ 2 which was within the MSBOS criteria.

DISCUSSIONThe cases in which the CT ratio of 2 or more was present were LSCS, vaginal hysterectomy, exploratory laparotomy, open cholecystectomy, Whipple’s procedure, CBD exploration, TUR(BT), pyelolithotomy, ureterolithotomy, spine surgery, ankle arthrodesis, PDA and sternotomy.This study revealed different factors in which the MSBOS recommendation of CT ratio can be affected.2 The first factor is the distance at which the blood bank was located and the ability of the blood bank to provide

Table 5: Showing distribution of cases in various cardiothoracic surgeries

S. No Surgical procedure No. of cases

X- matched TransfusedC/T Transfusion

ProbabilityTransfusion

IndexUnits Pts Units Pts1 PDA 8 7 2 1 1 7 50% 0.52 Decortication 4 4 4 2 4 2 100% 0.53 Sternotomy + excision of mediastinal mass 4 8 4 2 2 4 50% 0.54 Right lower lobe Lobectomy 1 2 1 2 1 1 100% 2

blood in emergency situations.2 Thus, cases like LSCS and open cholecystectomies, which would require only blood grouping and screening, blood was cross-matched and released due to fear of unavailability of blood if emergency situation would occur. Therefore, the distance and efficiency of blood bank affects the confidence of the surgeons and the anesthesiologists.Secondly, the patient’s pre-operative condition does affect the CT ratio since the MSBOS algorithm uses the surgical procedures alone.3 In our study, we found that the CT ratio of the urological cases was very high because these patients looked anemic and blood was over-ordered and released.Thirdly, is the difficulty in calculating blood loss which is seen in cases like TUR(BT) for carcinoma urinary bladder, TUR(P) where blood is mixed with urine3 and in hospitals where the same chest swabs or pad is reused after dipping in saline. It may also be expected in hospitals where facilities and coaching for proper assessment of blood loss is not available.Fourthly, wastage of blood due to inoperability of the disease (cancer). Thus, in such cases, it is best to release blood units only after the surgeon had decided to proceed further after the exploratory laparotomy.4

Lastly, blood wastage also depends on the surgeons and the anesthesiologists. The surgeons, depending on their expertise may cause more or less blood loss for a particular surgery. Anesthesiologists on the other hand, would transfuse a patient in which no indication for transfusion could be found. Despite much studies and evidence based guidelines for transfusion, inappropriate transfusion still happens.5

In many blood transfusion centres, large number of units of blood are cross-matched each day for patients who are most unlikely to require transfusion. Thus, each hospital can have a schedule of expected blood usage for each surgical procedure produced by analyzing their hospital data. However, it is necessary to analyze data retrospectively over a period of six months and collect a sufficient number of each procedures to give a meaningful assessment. In drawing up the ‘schedule’, attention must be paid to factors that would affect the speed of provision of compatible blood such as, the distance of the operating rooms from the blood bank

32 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

‘maximum surgical blood order schedule’

1. Friedman BA, Oberman HA, Chadwick AR, Kingdom KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976;16:380-387. [Medline]

2. Anonymous guidelines for implementation of a maximum surgical blood order schedule. The British Committee for standards in Haematology Blood Transfusion Task Force. Clin Lab Haematol 1990;12:321-327. [Medline]

3. Palmer T, Wahr JA, O’Reilly M, Greenfield MVH. Reducing unnecessary cross-matching: A patient specific blood ordering system is more accurate in predicting who will receive a blood ordering system. Anesth Analg 2003;96:369-375. [Medline] [Free Full Article]

4. Vibhute M, Kamath SK, Shetty A. Blood

utilization in elective general surgery cases: requirements, ordering and transfusion practices. J Postgrad Med 2000;46:13-17. [Medline] [Free Full Article]

5. Hasley P.B, Lave JR, Kapoor WN. The necessary and the unnecessary transfusion: a critical review of reported appropriateness rates and criteria for red cell transfusions. Transfusion 1994;34:110-5. [Medline]

6. Jo KI, Shin JW. Can maximum surgical blood order schedule be used as a predictor of successful completion of bloodless surgery? Ann Lab Med. 2013 Mar;33(2):116-20. [Medline] [Free Full Article] doi: 10.3343/alm.2013.33.2.116. Epub 2013 Feb 21.

7. Dexter F, Ledolter J, Davis E, Witkowski TA, Herman JH, Epstein RH. Systematic criteria for type and screen based on procedure’s probability of erythrocyte transfusion.

Anesthesiology 2012 Apr;116(4):768-78 [Medline] [Free Full Article] doi: 10.1097/ALN.0b013e31824a88f5.

8. Oliveira A, Fleming R, Galvão M. The maximum surgical blood order schedule. Acta Med Port 2006 Sep-Oct;19(5):357-62. [Medline] [Free Full Article]

9. Jayaranee S, Prathiba R, Vasanthi N, Lopez CG. An analysis of blood utilization for elective surgery in a tertiary medical centre in Malaysia. Malays J Pathol 2002 Jun;24(1):59-66. [Medline]

10. Mann K, Sim I, Ali T, Chong P, Leopold P, Hatrick A, Gerrard D. Removing the need for crossmatched blood in elective EVAR. Eur J Vasc Endovasc Surg. 2012 Mar;43(3):282-5. doi: 10.1016/j.ejvs.2011.11.026. Epub 2011 Dec 17. [Medline]

REFERENCES

and the availability of the transport facility. Thus, during the establishment of the schedule of MSBOS, emphasis should be laid on local circumstances, clinical practice and patients’ variables. This schedule should be reviewed regularly and adjustments made as necessary for the schedule to be effective.1

CONCLUSIONIn conclusion, the study emphasized that the MSBOS, established in a hospital by a team of operating surgeons, anesthesiologists and hematologists can reduce the over-ordering of blood, and the blood ordering pattern needs a time to time review for proper usage of blood.

ReMeMBeR yoUR HIsToRyAPICARE is interested in starting a new permanent series of articles on interesting history of anesthesiol-ogy, intensive care, pain management or resuscitation.The idea is to provide fresh appraisal to our younger colleagues about the difficulties and hardships faced by pioneers in these specialties and their enthusiasm and insight to realize an existing need and accepting the challenge to bridge the gap between the need and the provision. The manuscript should preferably be about 2500 to 3500 words with 5-25 references. Accompanying high definition pictures are most welcome but must be sent with relevant permission of copyright holders to reuse under the existing laws. Interested scholars may contact Editor-in-Chief at apicjournal@gmail.com

Editor-in-Chiefwww.apicareonline.com

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 33

oRIGINAL ARTIcLe

comparison of intravenous butorphanol, ondansetron and tramadol for control of shivering during regional anesthesia: A prospective, randomized double-blind studyJoshi Smita Suresh, MD, DA*, Adit Arora, MBBS**, Arun George, MBBS**, Shidhaye Ramchandra Vinayak, MD, DA***

*Professor; **Resident Department of Anesthesiology and Critical Care, Dr. D.Y. Patil Medical College Pimpri, Pune 411018 (India)

***Professor of Anesthesiology and Critical Care Pravara Institute of Medical Sciences, Loni 413736 (India)

Correspondence: Dr.R.V.Shidhaye, Shraddha Clinic, Babhaleshwar Tal. Rahata, Dist. Ahmednagar-413737 (India); Phone: 02422 253459; Cell: +91 9822034601; E mail: rvshidhaye@yahoo.com

ABSTRACTAim: We conducted this study to compare the efficacy and safety of butorphanol, ondansetron and tramadol for control of shivering in patients undergoing surgical procedures under spinal anesthesia.

Methodology: In this prospective double-blind, randomized, controlled study, 150 patients of both genders, 18-60 years old, ASA I or II, booked for elective surgery under spinal anesthesia were randomly distributed into three groups of 50 each. Each patient, who developed shivering, was given either 0.03 mg/kg of inj. butorphanol 1% (Group-B), 0.06 mg/kg of inj. ondansetron (Group-O) or 1.0 mg/kg of inj. tramadol 1% (Group-T) IV. Demographic characteristics, incidence of shivering, response rate after 1, 3, 5, 10 and 20 min, recurrence rate, hemodynamic parameters and complications were observed.

Results: All patients were relieved of shivering after butorphanol; 66.6% of them were relieved within 1 min, 93.33% within 3 min and 100% within 5 min. Ondansetron could relieve shivering in only 29.4% of the patients; 5.88% within 1, 11.76 % within 3, 23.52% within 10 and 29.4 % within 20 min. Tramadol relieved shivering in 92.30%; 46.15% within 1, 84.61% within 3 and 92.30% within 5 min respectively (p < 0.05). Recurrence of shivering was observed in 26.67% of butorphanol group and 15.38% of tramadol group (p> 0.05).

Conclusion: Ondansetron was not found to be much effective for the control of shivering during regional anesthesia. Butorphanol and tramadol were equally effective in controlling shivering under regional anesthesia, the only difference being in their onset of action. Butorphanol was quicker in onset which is essential for control of shivering and should be preferred.

Keywords: Perioperative shivering; Spinal anesthesia; Regional anesthesia; Tramadol; Ondansetron; Butorphanol; Thermoregulatory center

Citation: Joshi SS, Arora A, George A, Shidhaye RV. Comparison of intravenous butorphanol, ondansetron and tramadol for shivering during regional anesthesia: A prospective randomized double-blind study. Anaesth Pain & Intensive Care 2013;17(1):33-39

Running Title: Butorphanol, ondansetron and tramadol for control of shivering during regional anesthesia

INTRODUCTIONShivering is one of the most common complications of a central neuraxial blockade, due to impairment of the thermoregulatory control.1 It has been reported in 40 to 70% of patients undergoing surgery under regional anesthesia.2,3 Shivering, an involuntary, oscillatory muscular activity, is a physiological

response to core hypothermia in an attempt to raise the metabolic heat production.2 Prolonged impairment of thermoregulatory autonomic control under anesthesia along with the cold environment of operating rooms and cold infusion fluids, contributes to a fall in core body temperature, and hence shivering.2,4 Other known causes of shivering include transfusion reactions, drug reactions, pre-existing high grade fever or bacteremia,

34 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

control of shivering during regional anesthesia

or infusion of contaminated intravenous fluids (fungal growth in dextrose containing fluids). Perioperative hypothermia is the most common cause of shivering, though the exact incidence of each is difficult to evaluate.

It causes arterial hypoxemia due to 200–500% increase in oxygen consumption, a liner increase in carbon dioxide production,5 lactic acidosis, increased intraocular pressure (IOP) and increased intracranial pressure (ICP); and interferes with pulse rate, blood pressure (BP) and electrocardiographic (ECG) monitoring.6-8 Thus in a patient with limited myocardial oxygen reserve or known coronary disease, shivering may further compromise myocardial function.9 It may contribute to increased wound pain, delayed wound healing, and delayed discharge from post anesthetic care.4 It is very unpleasant, physiologically stressful for the patient undergoing surgery, and some patients find the accompanying cold sensation to be worse than the surgical pain. All these deleterious effects warrant primary prevention and prompt control on occurrence of shivering.

A number of pharmacological interventions have been studied for the treatment and prophylaxis of shivering, including clonidine, ketamine, butorphanol, doxapram, tramadol, pethidine and other opioids, ondansetron and other 5HT3 receptor antagonists.4,10-

14 Ondansetron is 5HT3 receptor antagonist, primarily used to prevent emesis. It has also been tried successfully for prevention of shivering in dose of 8mg IV without any side effects.15 We could not find studies that directly compare ondansetron to other two opioids, butorphanol and tramadol regarding its efficacy.

In this study we compared these three drugs regarding their efficacy and safety as an antishivering agent, aiming to find more effective, faster and safer agent to control shivering after regional anesthesia. Primary outcome measure was response rate within one minute after injecting the study drug. Secondary outcome measures were incidence of shivering, response rate after 3, 5, 10 and 20 min, total response rate, recurrence rate, hemodynamic parameters in patients having shivering and complication rate.

METHODOLOGYA prospective double-blind, randomized study, designed with three parallel groups was conducted at Pad. Dr. D. Y. Patil Medical College Hospital Pimpri, Pune (India) during the period from June 2007 to May 2008. After obtaining approval from the institutional ethical committee, 150 patients of both genders, of age group between 18-60 years, and of American Society of

Anesthesiologists physical status (ASA) I or II, booked for elective surgery under spinal anesthesia were enrolled in the study. Informed consent was obtained from all the patients. Exclusion criteria were severe systemic disorders like diabetes mellitus, hypertension, obesity (body mass index of ≥40 kg/m2), compromised cardiovascular and respiratory conditions, renal insufficiency, peptic ulcer disease, thyroid disease, abnormal psychological profile, acute infections e.g. upper respiratory tract infection or urinary tract infection etc., and fever due to any other cause, allergy to any of the study drugs and all known contraindications to spinal anaesthesia. Patients unwilling to get enrolled in the study, unwilling for spinal anesthesia and those on long term phenothiazines and MAO inhibitors were also excluded from the study. Patients were randomly distributed into three groups of 50 patients each and randomization was concealed.

Group-B (Butorphanol group): In this group, each patient, who developed shivering, was given 0.03 mg/kg of inj. butorphanol 1% intravenously (IV.) It was considered as control group.

Group-O (Ondansetron group): In this group, each patient, who developed shivering, was given 0.06 mg/kg of inj. ondansetron IV. It was considered as study group.

Group-T (Tramadol group): In this group, each patient, who developed shivering, was given 1.0 mg/kg of inj. tramadol 1% IV. It was also considered as study group.

Method of Randomization: A 2-operator technique was employed to maintain blinding. The cases were randomly allocated (sealed envelope technique using computer generated random numbers) to one of three groups by an investigator selected to prepare the study drug solutions. Further interventions and monitoring were done by an investigator blinded to the group allocation.

Sample size and power calculations: Sample size was based on previous study of Maheshwari BS et al,13

where shivering was controlled within 2 min in 92% of patients who received tramadol as compared to 28% of patients who received butorphanol. To detect a 64% difference in the response rate among the groups with 90% power and 5% alpha error (2-tailed), sample size of 13 cases per group was required. Previous studies found an incidence of shivering of the order of 40–70%.2, 3 Considering this we decided to take the sample size of 50 patients per group. Post-hoc power analysis was carried out for response rate within 1 minute. This study had 95% power to detect effect size of 60.78 between Group-B and Group-O and power of 60%

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 35

original article

to detect effect size of 40.27 between Group-T and Group-O.

All patients were administered 0.5% bupivacaine 3-4 ml intrathecally, at L2-L3 or L3-L4 interspinous spaces, with 26G Quinke’s spinal needle after preloading with 6-8 ml/kg of lukewarm crystalloid infusion and after recording the baseline vital parameters, e.g. pulse rate, blood pressure (BP), ECG, oxygen saturation (SpO2), and axillary temperature. Sedatives and hypnotics inclusive of opioids were avoided in pre-medication as well as intra-operatively. Ambient temperature of the operating room and recovery room was maintained at 22–28°C.

After induction of spinal anesthesia, patients were observed for the occurrence of shivering, its disappearance, hemodynamic status and complications (if any) until the postoperative period. The intensity of shivering was graded on a scale 0–3 as: 0=no shivering; 1=shivering observed in face and head (mild), 2=visible tremors involving more than one group of muscles (moderate), 3=gross muscular activity involving the entire body / bed shaking (most severe degree). Only cases that developed shivering of grade 2 or 3 during the perioperative phase were given treatment on an intention to treat basis. At the onset of shivering (grade 2 or 3), all patients were given oxygen via face mask at 6 L/min and 1 ml of studied drug as per group allocation. Shivering control was defined as complete when the shivering score declined to 0, incomplete when the scores decreased but did not abolish the shivering completely, and failed if no change in scores was observed. The time taken for cessation of rigors and hemodynamic changes were observed at intervals of 1 min till 5 min and thereafter at 10, 20, 30, 45 and 60 min. Pulse rate, BP, ECG, SpO2, respiratory rate and axillary temperature were noted immediately after regional anesthesia and during shivering and after drug administration at regular intervals. We did not

use the nasal, esophageal or rectal probes for electronic temperature monitoring. Recurring (any rise in shivering scores post treatment), and side effects of the study drugs were noted in each group.

After completion of the study a statistical analysis was done, using the ANOVA test, paired t-test and chi square test. Statistical analysis was done using SPSS software, version 10.

RESULTSPatients from all groups were comparable regarding age, gender, height, weight and ASA status (Table 1). Overall incidence of shivering was found to be 30% as shown in Table 2. The incidence of shivering in the butorphanol group was 30%, in the ondansetron group 34% and in the tramadol group it was 26% (p>0.05). So 15 subjects received butorphanol, 17 subjects received ondansetron and 13 received tramadol. Butorphanol was found to be most effective among all study drugs in relieving shivering as it produced complete relief within one minute in more patients (66.66%) as compared to with tramadol and ondansetron (46.15% and 5.88% respectively). All patients were relieved of shivering after butorphanol; 66.6% within 1 minute, 93.33% within 3 min and 100% within 5 min, whereas ondansetron relieved shivering in only 29.4% patients; 5.88% within 1 minute, 11.76 % within 3 min and 23.52 within 10 min and 29.4% within 20 min . 70.6% of the patients who received ondansetron had no relief at all. In tramadol group 92.3% patients were relieved of shivering; 46.15% within 1 min, 84.61 % within 3 min, 92.3% within 5 min and no relief in 7.7% of patients. The difference in the relief of shivering was highly significant at 1 min (p < 0.01). Comparing the ondansetron group with the tramadol group, tramadol was found to be more effective in controlling shivering while both tramadol and butorphanol were found to be equally effective after 5 min (Table 3).

Table 1: Demographic characteristics

Characteristics Butorphanol Group(n = 50)

Ondansetron Group(n = 50)

Tramadol Group(n = 50)

Age in years 36.5 ± 14.89 36.5 ± 13.06* 38.22 ± 16.75*Height in cm. 164.86 ± 0.95 164.54 ± 11.09* 164.06 ± 11.43*Weight in kg 64.1 ± 11.42 62.44 ± 12.66* 62.34 ± 10.79*

GenderMale 28(56) 31(62)* 27(54)*

Female 22(44) 19(38)* 23(46)*

ASA GradeI 42(84) 31(62) 36(72)II 8(16) 19(38) 14(28)

Data given as Mean ± SD or N(%)*p-value > 0.05 **p-value significant at 0.05; ***p-value significant at 0.01

36 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

control of shivering during regional anesthesia

Table 2: Incidence of shivering in three groups

Shivering Butorphanol Group(n = 50)

Ondansetron Group(n = 50)

Tramadol Group(n = 50)

Total

Present 15 (30%) 17 (34%) * 13 (26%) * 45 (30%)Absent 35 (70%) 33 (36%) * 37 (74%) * 105 (70%)Total 50 (100%) 50 (100%) 50 (100%) 150 (100%)

*p-value > 0.05 **p-value significant at 0.05; *** p-value significant at 0.01

Table 3: Relief of shivering after giving study drug

Relief after injecting the drug Butorphanol Group(n = 15)

Ondansetron Group(n = 17)

Tramadol Group(n = 13)

Within 1 minute 10 (66.66) 1 (5.88) 6 (46.15)***

Between 1 to 3 min 4 (26.67) 1 (5.88) 5 (38.46)**Between 3 to 5 min 1 (6.67) 0 (0) 1 (7.69)*Between 5 to 10 min 0 (0) 2 (11.76) 0 (0)*Between 10 to 20 min 0 (0) 1 (5.88) 0 (0)*No relief at all 0 12 (70.60) 1 (7.70)**Recurrence of shivering 4 (26.67) 0 (0) 2 (15.38)*

*p-value > 0.05 **p-value significant at 0.05; ***p-value significant at 0.01

Table 4: Hemodynamic parameters in patients having shivering

Parameter Butorphanol Group(n = 15)

Ondansetron Group(n = 17)

Tramadol Group(n = 13)

Heart rate (per min)Pre shivering 78.53 ± 16.23 77.82 ± 12.35 77 ± 10.17*Intra shivering 81.53 ± 14.80 79.12 ± 11.12 79.57 ± 10.74*Post shivering 78.67 ± 13.57 76.89 ± 7.88 78.86 ±20.69*

Systolic Blood Pressure (mmHg)Pre shivering 118.73 ± 11.92 120.18 ± 13.29 115.43 ±10.05*Intra shivering 116.13 ± 11.43 118.71 ± 14.81 113 ± 11.79*Post shivering 118.2 ± 10.13 123.22 ± 7.89 112.86 ±9.86*

DiastolicBlood Pressure (mmHg)Pre shivering 74.4 ± 10.36 73.18 ± 12.72 71.14 ±9.06*Intra shivering 65.87 ± 13 67.76 ± 9.11 64.71 ± 9.07*Post shivering 70.13 ± 9.54 72.22 ± 9.15 68.57 ± 8.48*

Axillary temperature (°C) Average 36.8 ± 0 36.74 ± 0.40 36.66 ± 0.41*

* p-value > 0.05 **p-value significant at 0.05; *** p-value significant at 0.01

Table 5: Incidence of Complications

Complications Butorphanol Group(n = 15)

Ondansetron Group(n = 17)

Tramadol Group(n = 13)

Sedation 7(46.67) 0 0***Itching 1(6.67) 0 0*Nausea 0 0 4(30.77)***Vomiting 0 0 1(7.69)*

* p-value > 0.05 **p-value significant at 0.05; *** p-value significant at 0.01

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 37

original article

The recurrence of shivering was noted in 26.67% of patients in butorphanol group and in 15.38% of patients in tramadol group (p> 0.05) (Table 3). Table 4 shows hemodynamic status of the patients. There was no significant difference between three groups systolic and diastolic blood pressure and heart rate. There was also no significant differences in pre-, intra- and postshivering heart rate, systolic and diastolic blood pressures in any of the three groups. Axillary temperature, too, showed no differences in the groups. Table 5 shows the incidence of complications in study groups. In the butorphanol group 46.66% of the patients were sedated compared to none in the other group. One patient in the butorphanol group but none in the other two complained of itching. Four patients in the tramadol group complained of nausea and one had vomiting. This complication was noted in none of the other two groups.

DISCUSSIONRegional anesthesia, either central neuraxial block or peripheral nerve block is a safe and very popular technique used for various surgeries. However, 40-70% of patients undergoing regional anesthesia develop shivering, though it is also found to occur after general anesthesia.2,3 The mechanism which leads to shivering after regional anesthesia is not very clear, but the probable mechanisms could be decrease in core body temperature secondary to sympathetic block; peripheral vasodilatation; increased cutaneous blood flow, which leads to increased heat loss through skin; cold temperature of operation theatre; rapid infusion of cold IV fluids; and effect of cold anesthetic drugs upon the thermosensitive receptors in the spinal cord.16,17 There are many pharmacological and non-pharmacological methods used to prevent heat loss and decrease shivering. Non-pharmacological methods include radiant heat warmers, warming the operation theatre, blankets, warm IV fluids and using anesthetic drugs at body temperature.18,19 It has been mentioned that hypothermia may cause postanesthetic shivering by alteration of thermoregulatory mechanism.20 However, no relationship has been shown between axillary temperature and occurrence of shivering.20

Rigors occur commonly, as a protective response to core hypothermia, though it may occur in the presence of normothermia.10 In our study, there was no significant difference in axillary temperature among the groups. We had to resort to continuous measurement of axillary temperature by electronic monitors as we felt that a nasal, esophageal or rectal probe would be uncomfortable for the patients. A number of factors including age, duration of surgery, temperature of the

operating room, and infusion solution, are risk factors for hypothermia and shivering.21 So in our study, patients over the age of 60 years were excluded. The temperature of operating room was maintained at 22° to 28° C and infusions of crystalloid solution were warmed. This was probably the reason for lower overall incidence of shivering (30%) in our study as compared to other studies. We also excluded the patients having history of acute infections, sepsis and fever to reduce their confounding effect. Pharmacological intervention does not raise body temperature, but resets the shivering threshold to a lower level, thereby decreasing rigors and its episodes. Various pharmacological therapies have been tried to prevent or treat shivering, including opioids (e.g. pethidine, nalbuphine, butorphanol or tramadol), ketanserin, propofol, ondansetron, granisetron, doxapram, physostigmine, clonidine, and nefopam etc., but debate for an ‘ideal anti-shivering drug’ still continues.4,22 Tramadol hydrochloride, a μ-opioid receptor agonistic drug, has a modulatory effect on central mono-aminergic pathways, and thus inhibits the neuronal uptake of noradrenaline/serotonin and encourages hydroxytryptamine secretion which resets the body temperature regulation center. It has gained a reputation in many clinical trials for the control of shivering.6,8,23 Butorphanol, an easily available opioid, acts through k and μ receptor agonistic modulation, though only a few studies have denoted its antishivering properties.10,13 5-hydroxytryptamine (5-HT3) may influence both heat production and heat loss pathways.21 Ondansetron and dolasetron, both 5-HT3 antagonists, have been effectively used in the treatment of postoperative shivering.24,25

In the present study, we compared the efficacy of butorphanol, ondansetron and tramadol for treatment of shivering after spinal anesthesia in patients undergoing various elective surgeries. All groups were comparable with regard to demographic characteristics. We found that butorphanol was as effective as tramadol in treating post-spinal anesthesia shivering, but the time to control of shivering was significantly less with butorphanol. The response rate was also higher in the butorphanol group than in the tramadol group, but the difference was not statistically significant (p>0.05). Shivering is so distressing to the patient that quick response to antishivering agent is appreciated. Keeping this in mind we compared these drugs in respect of ‘response within one minute’ rate. We found butorphanol more effective than the other two drugs and ondansetron far less effective than the other two drugs regarding this. Regarding total response rate too,

38 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

control of shivering during regional anesthesia

ondansetron was found to be far inferior to the other two drugs. In contradiction to our findings, Ebru K et al26 found ondansetron as effective as meperidine in controlling shivering. However, they used ondansetron in a dose of 8 mg as against 4 mg used by us. There was no significant difference between butorphanol and tramadol regarding total response rate after 5 min (100% as against 92.3%). Bansal et al10 also found similar difference in butorphanol (83%) and tramadol (73%) in respect of total response rate (complete cessation of shivering after treatment) which was not significant (p>0.05). Tramadol and butorphanol both had comparable results in complete suppression of shivering which accords with observations made by earlier investigators.6,27,28 A higher incidence of recurrence of rigors was observed in tramadol treated patients in a study of Bansal et al,10 which is in contrast to observations made by Maheshwari et al,13 who observed a lower rate of recurrence with tramadol compared with butorphanol (8% vs. 25% respectively). We could not find statistically significant difference among the groups regarding recurrence. Sedation was noted in more in patients in butorphanol group and nausea more in tramadol group. Contrary to our results, Maheshwari et al13 found a higher incidence of vomiting with butorphanol compared with tramadol. Bansal et al10 found no difference in butorphanol and tramadol. All the three drugs were comparable regarding hemodynamic safety. There were no significant alterations during, pre- and post shivering period, after administration of all the three

drugs similar to the results of Maheshwari et al13 and Mathews et al.29

Limitations: The limitations of our study include a relatively small sample size in proportion to the burden of this perioperative problem. The results of our study may not coincide with studies done on other ethnic populations owing to variations in body surface area and their heat or cold tolerability. Another limitation of this study is that we could not measure the core body temperature. For measurement of core body temperature, the probe needs to be put in the esophagus or near the tympanic membrane. Both these are uncomfortable and unacceptable who has been given spinal anesthesia. Rectal temperature monitoring was a possibility but was not tried. One more limitation of our study is that we did not document the sepsis markers as PCT, CRP, etc. though we excluded the patients from study having fever and sepsis to reduce their confounding effect.

CONCLUSION

The incidence of shivering in our study was about 30%. Ondansetron was not found to be much effective for the control of shivering during regional anesthesia. Butorphanol and tramadol were equally effective in controlling shivering under regional anesthesia, the only difference being in their onset of action; butorphanol was quicker in onset which is essential for control of shivering and so should be preferred.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 39

original article

1. Ozaki M, Kurz A, Sessler DI, Lenhardt R, Schroeder M, Moayeri A, et al. Thermoregulatory thresholds during spinal and epidural anesthesia. Anesthesiology 1994;81:282-8 [Medline] [Free Full Text]

2. Witte JD, Sessler DI. Perioperative shivering: Physiology and Pharmacology. Anesthesiology 2002;96:467-84. [Medline] [Free Full Text]

3. Sessler DI, Ponte J. Shivering during epidural anesthesia. Anesthesiology 1990;72:816-21. [Medline] [Free full text]

4. Kranke P, Eberhart LH, Roewer N, Tramer MR. Pharmacological treatment of postoperative shivering: a quantitative systematic review of randomized controlled trials. Anesth Analg. 2002;94:453–460. [Medline] [Free Full Text]

5. Dal D, Kose A, Honca M, Akinci SB, Basgul E, Aypar U. Efficacy of prophylactic ketamine in preventing postoperative shivering. Br J Anaesth 2005;95:189–192. [Medline] [Free Full Text]

6. Bhatnagar S, Saxena A, Kannan TR, Punj J, Panigrahi M, Mishra S. Tramadol for postoperative shivering: A double blind comparison with Pethidine. Anaesth Intensive care 2001;29:149-54. [Medline]

7. Sessler Daniel I. Temperature Monitoring. Millar RD, 5 th ed. Textbook of Anesthesia. Churchill Livingstone Inc, New York, 1994. p. 1367-89

8. Katyal S, Tewari A. Shivering: Anesthetic Considerations. J Anaesth Clin Pharmacol 2002;18:363-76

9. Buggy DJ, Crossley AWA. Thermoregulation, mild perioperative hypothermia, and post-anaesthetic shivering. Br J Anaesth 2000;84:615–628. [Medline] [Free Full Text]

10. Bansal P, Jain G. Control of shivering with clonidine, butorphanol, and tramadol under spinal anesthesia: a comparative study. Local Reg Anesth 2011;4:29–34. [Medline] [Free Full Text]

11. Alfonsi P. Postanesthetic shivering

epidemiology, pathophysiology and approaches to prevention and management. Drugs 2001;61:2193-205. [Medline]

12. Piper SN, Maleck WH, Boldt J, suttner SW, Schmidt CC, Reich DGP. A comparison of clonidine, meperidine and placebo in preventing postanesthetic shivering. Anesth Analg 2000;90:954-7. [Medline] [Free Full Text]

13. Maheshwari BS, Shah SK, Chadha IA. Tramadol and Butorphanol for control of shivering : Randomised double blind comparative study. J Anaesth Clin Pharmacol 2008;24(3):343-46. [Medline] [Free Full Text]

14. Komatsu R, Orhan-Sungur M, In J, Podranski T, Bouillon T, Lauber R, Rohrbach S, Sessler D. Ondansetron does not reduce the shivering threshold in healthy volunteers. Br J Anaesth. 2006;96(6):732-7. [Medline] [Free Full Text]

15. Kelsaka E, Sibel B, Deniz K, Binnur S. Comparison of ondansetron and meperidine for prevention of shivering in patients undergoing spinal anesthesia. Reg Anesth Pain Med 2006;31:40-45. [Medline]

16. Anne Miu Han Chan, Kwok Fu. Control of shivering under regional anesthesia in obstetric patients with tramadol. Can J Anaesth 1999;46(3):253-8. [Medline]

17. Chaturvedi S, Domkondwar G. Control of shivering under regional anesthesia using Tramadol. Asian Archives of Anaesthesiology and Resuscitation 2002;57:491-6

18. Ikeda T, Sessler DI, Tayefeh F, Negishi C, Turakhia M, Marder D, et al. Meperidine and Alfentanyl do not reduce the gain or maximum intensity of shivering. Anaesthesiology 1998;88:858-65. [Medline] [Free Full Text]

19. Wrench IJ, Cavill G, Ward JE, Crossley AW. Comparison between Alfentanil, Pethedine, and placebo in the treatment of postoperative shivering. Br J Anaesth 1997;79:541-2. [Medline] [Free Full Text]

20. Vanderstappen I, Vanermeerch E, Vanacker B,

Mattheussen M, Herijgers P, Van Aken H. The effect of prophylactic clonidine on postoperative shivering: a large prospective double-blind study. Anaesthesia 1996;51:351-5. [Medline]

21. Crowley LJ, Buggy DJ. Shivering and neuraxial anesthesia. Reg Anesth Pain Med 2008 May-Jun;33(3):241-52. [Medline] doi: 10.1016/j.rapm.2007.11.006.

22. Zhang Y, Wong KC. Anaesthesia and postoperative shivering: its etiology, treatment and prevention. Acta Anaesthesiol Sin 1999;37:115–120. [Medline]

23. Zahedi H. Comparison of tramadol and pethidine for postanesthetic shivering in elective cataract surgery. Journal of Research in Medical Sciences 2004;5:235–239. [Free Full Text]

24. Bock M, Sinner B, Gottlicher M, Simon E, Martin E, Motsch J. Involvement of serotonergic pathways in pos¬tanesthetic cold defence: dolasetron prevents shivering. J Thermal Biol 2002; 27:159-66. [PMC Free Full Text]

25. Powell R, Buggy D. Ondansetron given before induction of anesthesia reduces shivering after general anesthesia. Anesth Analg 2000;90:1413-7. [Medline] [Free Full Text]

26. Ebru Kelaska, Korakaya D. Comparison of ondansetron and meperidine for prevention of shivering in patients undergoing spinal anesthesia. Reg Anesth Pain Med 2006;31(1):40-45. [Medline]

27. Atashkhoyi S, Negargar S. Effect of tramadol for prevention of shivering after spinal anesthesia for cesarean section. Research Journal of Biological Sciences 2008;3:1365–1369.

28. Dhimar AA, Patel MG, Swadian VN. Tramadol for control of shivering: comparison with Pethidine. Indian J Anesthesia 2007;51:28–31. [Journal Free Full Text]

29. Mathews S, Al Mulla A, Varghese PK, Radim K, Mumtaz S. Post-anaesthetic shivering: A new look at tramadol. Anesthesia 2002;57:387-403. [Medline]

REFERENCES

40 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

oRIGINAL ARTIcLe

A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (sri Lanka)M.V.G. Pinto, MBBS, MD, FRCA, FCARCSI*, R Varun, MBBS**, W. M. M. P. B. Wanasinghe, MBBS**, T. M. K. Jayasinghearachchi, MBBS**, H. M. T. A Herath, MBBS**, P. V. R. Kumarasiri, MBBS, MD, PhD***

*Consultant Anesthesiologist / Senior lecturer, **Lecturer Department of Anesthesiology, Faculty of Medicine, University of Peradeniya, Peradeniya (Sri Lanka)

***Senior LecturerDepartment of Community Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya (Sri Lanka)

Correspondence: Dr. (Mrs.) M. V. G. Pinto, Head, Department of Anesthesiology, Faculty of Medicine, University of Peradeniya, Peradeniya (Sri Lanka); Phone: 0094773662199; Email: vasantipinto@yahoo.com

ABSTRACTObjectives: The aim of this study was to evaluate the knowledge and attitudes about Do Not Resuscitate orders, Advance Directives and Withdrawal or Withholding of life-sustaining therapy among medical professionals.

Study Design: Descriptive, cross-sectional study

Setting: The study was conducted in three teaching hospitals, General Hospital Kandy, Teaching Hospital Peradeniya and Teaching Hospital Gampola of Kandy District (Sri Lanka).

Methodology: 232 medical professionals were randomly selected. Data were collected using a pre-tested self-administered questionnaire. The knowledge and attitude was assessed with regard to ‘Advance Directives’, DNR orders and ‘withdrawal/ withholding life sustaining care’, by scenario based questions and several close-ended questions. Data were analyzed with SPSS v17.0 and Pearson Chi Square was calculated.

Results: The age range of the study population (n=232) was 26-56 years and majority of the participants were male (64.2%). Most of the medical professionals were Buddhists (88.4%). Out of the subjects, 66.8% (p<0.001) had heard the term ‘DNR’, while 26.3% knew the correct meaning and 68.1% (p<0.001) thought it to be ethical to practice it in Sri Lanka. The number of medical professionals feeling that patient, doctor or the family should have the right to decide on end-of-life decisions was 62.9% (p=0.005), 62.9% (p=0.005) and 46.6% (p=0.46) respectively. 20.7% had heard about ‘Advance Directives’ but only 12.1% knew the correct meaning; 62.5% had heard about ‘withdrawal/withholding of life sustaining therapy’ (p=0.006) and 65.9% opined that it should be implemented in Sri Lanka (p<0.001).

Conclusion: The knowledge about end-of-life decisions among medical professionals working in three major teaching hospitals of Kandy district is inadequate. The majority of the medical doctors have positive attitude towards end-of-life decisions implementation in Sri Lanka.

Key words: End of life decisions; DNR; Advance Directives; Withdrawal of care; Internet

Citation: Pinto MVG, Varun R, Wanasinghe WMMPB, Jayasinghearachchi TMK, Herath HMTA. Kumarasiri PVR. A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (Sri Lanka). Anaesth Pain & Intensive Care 2013;17(1):40-44

INTRODUCTIONMutual consultation by physicians and patients has become an ideal way of medical decision making. In the present era patients must be informed about

and understand the nature of their illness, proposed treatment, likely outcomes and alternatives.1 Novel clinical practice of critical care medicine employs many end-of-life decisions e.g. ‘Advanced Directives’, ‘Do-

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 41

original article

Not-Resuscitate orders’ and ‘withdrawal/withholding of life sustaining therapy’) which raise many ethical dilemmas. These medical decisions are based upon four principles, e.g. beneficence, non maleficence, autonomy and justice.2 Translating these principles into clinical practice in intensive care is not altogether easy. Principle of autonomy, may override beneficence when a decision is required to provide or withdraw life support.2 Advance Directive (AD) is a document which indicates decisions the patient would like to make if and when he is unable to participate in end-of-life decisions, as a living will or naming a health care surrogate.3

Do Not Resuscitate order (DNR) is legal order written to respect the wishes of a patient to not undergo cardiopulmonary resuscitation or advanced cardiac life support in an event of cardiac or respiratory arrest.4 However, DNR order does not affect provision of emergency medical care and treatment for pain. The DNR request is usually made by the patient when he/she is in a sound mind.2 The document must also be signed by the attending physician and two other witnesses.4

Withdrawal/withholding life sustaining therapy (WLT) refers to cessation of treatment which has the potential to postpone patient’s death, viz. cardio-pulmonary resuscitation, institution of artificial ventilation, infusion of blood and blood products, insertion of pacemakers, specialized treatments (e.g. chemotherapy or dialysis), antibiotics and artificial nutrition and hydration.5 The goal of this is to remove unwanted treatments rather than to hasten death.6

The treating physician plays a pivotal role in completion of patient-made DNR orders, and his expert opinion on decision making regarding WLT. Thus a physician’s knowledge about these documents and ethical issues is of prime importance. It has been suggested in many international studies done among doctors, that their awareness is inadequate.7-9 As these documents are not legally authorized in Sri Lanka, the awareness about these controversial issues among Sri Lankan medical professionals is questionable. Thus the aim of this study was to assess the knowledge and attitude about end-of-life decisions among Sri Lankan medical professionals as it has not been studied earlier.

METHODOLOGYAfter obtaining clearance from Ethical Committee of Faculty of Medicine, Peradeniya, this descriptive, cross sectional study was carried out among medical professionals, working at three teaching hospital of

Kandy district, e.g. General Hospital Kandy, Teaching Hospital Peradeniya and Teaching Hospital Gampola. The study area was selected on the basis of being teaching hospitals with multi-disciplinary teams.Sample size calculation: a pilot study involving 30 doctors of Teaching Hospital, Peradeniya, was performed to improve the validity of the questionnaire. During the planning stage of the study power calculation was performed considering the power (β) and significance (α) at 95% levels. The pilot study indicated that about 20% of doctors knew about DNR, AD and WLT. Thus according to these criteria and the World Health Organization publication on sample size determination,10 the calculated maximum sample size was 246. Due to practical implications and time limitations, only 232 subjects were recruited to the study. However, this number was adequate to maintain the power of 94.8% level. The 232 medical professionals were randomly selected as every third doctor entered the hospital doctor’s cafeteria from 8am to 4pm over a period of one month. Every doctor was subjected to the study only once.

All the medical practitioners registered with Sri Lankan Medical Council (possessing at least MBBS diploma with work experience of at least one year irrespective of their experience of sub-specialties) currently working in the selected institutions were included, while unwilling medical professionals, dental surgeons and pre-interns medical graduates serving in these institutions were excluded from the study.

Data were collected by using the pretested self-administered questionnaire after verbal consent had been obtained. The questionnaire covered following areas: Demographic data, knowledge and attitudes towards AD, DNR orders and WLT by means of a case scenario followed by several direct closed ended questions. The given case scenario was: “A 59 years old male, who had an active life, was diagnosed to have a terminal cancer. Now his condition is rapidly deteriorating, doctors have explained him all possible treatment options with their respective success and failure rates. They made him well aware of his situation. The patient underwent a palliative surgery, and is currently being ventilated in the ICU on a long-term. A multi-disciplinary team examined him and expressed that he has a higher chance of having a poor quality life”.

The questions included direct questions inquiring the meanings of the terms and applicability of them in Sri Lanka. In questions regarding the meaning of the terms the answers consisting of all the keywords of the standard definitions were counted as correct.

The first question based on the case scenario assessed the

42 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

knowledge and attitudes towards end-of-life decisions

attitude towards practice of patient’s autonomy over decision making authority. Followed by questions to evaluate the attitude on who should have the authority to decide. Subsequent questions inquired about the possession of such decision making power in Sri Lanka. Statistical analysis was performed using SPSS version 17.0, in terms of means and percentages for respective categories.

RESULTSDemographic data of the study population are given in Table I. Most of the subjects were male (64.2%) and majority of the study population consisted of Buddhists (88.4%). Sri Lankan population is made up of 70% Buddhists, 15 % Hindus, 8% Muslims and 7% Christians, according to the 2001 census statistics. Keeping up with this our study sample also consisted of mostly Buddhists. The mean age of the cohort was 35.6 years. There were 17 ICU medical officers and 27 medical postgraduates who had ICU training as a part of postgraduate training (Table 1).

Table 1: Demographic data of the study population

Characteristic Data

Gender [n (%)]Male 149 (64.2)Female 83 (35.8)

Religion [n (%)]

Budhists 205 (88.4)Hindus 9 (3.9)Christians 5 (2.2)Muslims 13 (5.6)

Age (Yrs)Range 26 – 56Mean 35.59

A significant proportion had heard of the terms DNR and WLT (66.8%, p<0.001 and 62.5%, p=0.006 respectively), while a significant number (p<0.001)

Table 2: Knowledge and understanding of DNR, Advanced Directives and withdrawal of care in an terminally ill patient

Ethical principleHeard about the term Knew the correct meaning

YesN (%)

NoN (%)

Source of KnowledgeN (% of total sample)

YesN (%)

NoN (%)

DNR

155(66.8) 77(33.2) Lecture- 26 (11.2)Internet- 24 (10.3)Work Experience- 44(18.9)Colleagues-6 (2.6)Media- 2 (0.9)

61(26.3) 171(73.7)

*p<0.001 *p<0.001

Advance directives48(20.7) 184(79.3) Lecture- 10 (4.3)

Internet- 15 (6.5)Work Experience- 11(4.7)

28(12.1) 204(87.9)

*p<0.001 *p<0.001

Withdrawal of care145(62.5) 87(37.5)

Not tested*p=0.006

* p value was determined using Pearson Chi Squared equation.

was unaware about AD, which is unsatisfactory. A substantial percentage of the cohort lacks the absolute understanding about the terms (Table 2). The work experience and internet has been the major contributors for the knowledge.The response rate was 100% and all of them attempted to the questions based on the case scenario, and the responses are shown in Table 3. Results depicted that once a patient is terminally ill and he is assured of medical futility a significant majority (i.e. 62.9%, p=0.005) think that this particular patient should have legal rights to forgo life sustaining treatment, where 46.6% (p=0.46) and 62.9% (p=0.005) agreed that the family and the doctor should also possess such power respectively (Table 3).Statistics reveal that significant proportion of participants agreed to implement DNR orders (p<0.001) and withdrawal of care (p<0.001) in Sri Lanka and most of them reasoned out the limited resources as the justification. 11 of the whole cohort thought that the practice of DNR is a sin and it should not be practiced (Table 4).

DISCUSSION

AD, DNR orders and WLT are issues widely practiced in the western world, but these are not legally advocated by legislation in SAARC nations including Sri Lanka. Despite the fact that these have not been legalised or legally practiced in our hospitals, every doctor is expected to have an updated knowledge about these issues which have gained more and more attention. ‘Is the current knowledge adequate?’ and ‘what are perceptions of the doctors?’ are the questions which need to be answered. In our study, the finding that only one fifth of the cohort knew the term ‘AD’ and out of them only 28 were able to correctly define the term revealed a gross inadequacy

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 43

original article

Table 3: Responses to close ended questions with regard to the case scenario

QuestionResponse [N (%)]

*p valueYes No Don’t know

Patient should have the power to decide to avoid treatment and life support 146 (62.9) 86 (37.1) 0 **p=0.005patient has the power to decide to avoid treatment and life support 58 (25.0) 128 (55.2) 46 (19.8) **p<0.001Family should have the power to decide to avoid treatment and life support 108 (46.6) 124 (53.4) 0 p=0.46Family has the power to decide to avoid treatment and life support 40 (17.3) 140 (60.3) 52 (22.4) **p<0.001Doctor should have the power to decide to avoid treatment and life support 146 (62.9) 86 (37.1) 0 p=0.005Doctor has the power to decide to avoid treatment and life support 92 (39.6) 96 (41.4) 44 (19.0) **p=0.84

* p value was determined using Pearson Chi Squared equation. ** p values calculated only between responses “Yes” and ”No”

Table 4: Attitudes on implementation of DNR orders and withdrawal of care. Data given as N (%)

Question Yes No Not responded

Reason to agreeN=108

Reason to disagreeN=14

Whether DNR is appropriate to be implemented in Sri Lanka

158(68.1) 40(17.2)34(14.7)

Limited resources 68(29.3)To reduce patient suffering 12(5.2)Patient’s autonomy 17(4.7)After recovery poor quality of life 17(7.32)

Sin or Unethical 11(4.7)

Chance of Misuse 3 (1.3)*p<0.001

Whether Withdrawal/Withholding of care is appropriate to be implemented in Sri Lanka

153(65.9) 53(22.9)26(11.2)

Limited resources 93(40.1)To reduce patient suffering 12(5.2)Patient’s autonomy 4(1.7)After recovery poor quality of life 6(2.6)

Sin or Unethical 9(3.9)

Chance of Misuse 5(2.2)*p<0.001

* p value was determined using Pearson Chi Squared equation.

of the knowledge on the subject in a significant majority (p<0.001). The novelty of the subjects and absence of the practice in our country may account for the finding. In contrast, a significant number had heard about ‘DNR’ orders and ‘WLT’ [66.8% (p<0.001) and 62.5% (p=0.006) respectively]. This finding may be because they encounter terminally ill patients in their day-to-day practice, although they do not exercise these documents. Owing perhaps to some lapses in the medical education on ethics, only a minority of the participants defined the term ‘DNR orders’ correctly. Informative undergraduate and postgraduate lectures, internet study material and implementation of more Continuing Medical Education (CME) programmes amongst clinicians might improve the basic knowledge and understanding about this subject.The moral duty to respect autonomy is now an established part of good clinical practice.11 Majority of the subjects’ agreement to empower the patient with right on his end-of-life decisions can be explained as an aspiration of the medical community towards practice of autonomy of Sri Lankan patients. The enlightenment by medical education on ethical subjects would also have influenced this finding. This is an upcoming trend in many affluent nations as well.2 Not many studies have been done with this regard but a study done by Miller in 1985 showed that many doctors prefer patients’ participation in such decision making events.1

Regarding provision of legal power to the family on behalf of the patient, to decide about WLT, 53.4% of the doctors disagreed, which is statistically insignificant (p=0.46). Yet it may be attributed to perceptions of the clinicians since the family members lack proper understanding due to emotional involvement and sympathy or might enable them to misuse such authority. Another explanation would be that in Buddhism, the first of the five precepts admonishes the destruction of life as a sin and also killing of a person intentionally or unintentionally is considered to be one of the five heinous crimes; thus as the majority of the participants were Buddhists (88.4%), this thought might have influenced the above finding. There are no published studies testing medical practitioners’ views in this regard. A doctor would like to bestow the right to decide upon end-of-life decisions to the patient’s family rather than do it all by himself, because of strong family bonds and the immeasurable trust placed upon next of kin and the cultural background. This may be the reason why 46.6% of doctors chose to entrust the decision making authority to the family of the patient.A significant majority (62.9%) (p=0.005) of the subjects held the idea that a doctor should have the authority to decide about WLT. This is in line with findings of an earlier study done by Rivera in 2010 on a group of doctors who were undergoing training, where a

44 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

knowledge and attitudes towards end-of-life decisions

majority thought that the physician should have a right to give a DNR order in the absence of an order from a comatosed patient.8 The better understanding about the disease process, patient’s history and the outcome of treatment, are the positive points for a doctor to think that he would be in a better position to decide on behalf of his patient than the patient himself or the family. But in our cohort, again the religious beliefs may have made 37.1% to disagree with the statement. The wrong perception that ‘Sri Lankans (a doctor, the patient or family) are provided with legal provision to act as surrogates’ in end-of-life decision making, may be due to lack of knowledge on basic legislation. Lack of review of medical ethics or practical expertise on these issues may be some of the contributory factors. Authorisation of DNR orders and WLT in our country was agreed by 75% (p<0.001) on the basis of resource scarcity and the assumption that hastening the death would terminate the needless patient suffering. The doctors’ liberal percept about the practice of his patients’ autonomy is a healthy outlook from a medical point of view. Out of 14 whom claimed it as inappropriate, 11 thought it to be a sin which is again expected with the South Asian cultural and religious beliefs. Only 3 of the doctors thought that the documents could be misused by the doctors for organ harvesting or misuse by next-of-kin for other means. Probably because of the dilemma between the knowledge and religious

views, 34 were inconclusive of its implementation.

The most important factors in the end-of-life decisions are the likelihood of cure and the chances of long-term disease free survival; yet the cultural background, religious preaching, federal legislation and the scope of medical education should also be taken into account prior to introduction into the legal system in Sri Lanka.

Suggestions: More lectures on medical ethics should be included in undergraduate curriculum and Continuing Medical Education programs should be organized for graduates and postgraduates. The need to respect the patient’s wishes and autonomy should be emphasized.

CONCLUSIONThe knowledge about end-of-life decisions among medical professionals working in three major teaching hospitals of Kandy district is inadequate. The majority of the medical doctors have positive attitudes towards end-of-life decisions on their implementation in Sri Lanka.

Acknowledgement: We express our sincere gratitude to all of the subjects for their valuable time and support. We also extend our gratitude towards all the administrative officers and heads of the departments for granting permission to collect data in the three institutions.

1. Miller A, Lo B. How do doctors discuss do-not-resuscitate orders? West J Med 1985;143:256-258. [Medline] [Free PMC Article]

2. Eckberg E, The Continuing Ethical Dilemma Of The Do-Not-Resuscitate Order. AORN J. 1998 Apr;67(4):783-7, 789-90. [Medline]

3. Braddock CH, Do Not Resuscitate Order. Ethics In Medicine. Washington: University of Washington, School of Medicine; 1998. Available http://depts.washington.edu/bioethx/topics/dnr.html. Accessed 16 November 2012

4. Zoch TW, Desbiens NA, DeStefano F, Stueland DT, Layde PM. Short- and long-term survival after cardiopulmonary resuscitation. Arch

Intern Med 2000;160(13):1969–73. [Medline]

5. BMA-British Medical Association, Withholding and Withdrawing Life-prolonging Medical Treatment: Guidance for decision making. London: BMJ Books; 1999.

6. Rubenfeld GD. Principles and practice of withdrawing life-sustaining treatments. Crit Care Clin. 2004 Jul;20(3):435-51,ix. [Medline]

7. Perron NJ, Morabia A, de Torrenté A. Evaluation of do not resuscitate orders (DNR) in a Swiss community hospital. J Med Ethics 2002 Dec;28(6):364-7. [Medline] [Free PMC Article]

8. Ramírez-Rivera J, Cánova-Díaz C, Hunter-Mellado R. Knowledge and

Implementation of the DNR in Internal Medicine Teaching Programmes. P R Health Sci J. 2010 Jun;29(2):96-101. [Medline]

9. Hildén HM, Louhiala P, Palo J. ‘End of life decisions: attitudes of Finnish physicians’. J Med Ethics 2004;30:362-5. [Medline]

10. Lwanga SK, Lemeshar S. Estimating a Population Proportion with Specified Absolute Precision. In: Sample Size Determination in Health Studies. Geneva: World Health Organization; 1991.

11. Medical ethics today, BMA-British Medical Association. London 1993. [Free e-book]

REFERENCES

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 45

INTRODUCTIONAnesthesia provision in the battlefield, hostile environment or in disaster situations encompasses the skills of resuscitation, the art of anesthesia, postoperative intensive care and safe patient transfer.1 The field conditions demand anesthetic techniques that allow rapid recovery and early evacuation.2-4 Experience has shown us that austerity is powerless in preventing success and high standards of care when faced with

oRIGINAL ARTIcLe

Use of a portable oxygen concentrator and its effect on the overall functionality of a remote field medical unit at 3650 meters elevationRehan Masroor, MBBS, MCPS, FCPS*, Amjad Iqbal, MBBS, FCPS**, Khalid Buland, MBBS, MCPS, FCPS***, Waqas Ahmad Kazi, MBBS, FCPS**** *Consultant Anesthesiologist, PAF Hospital Mianwali (Pakistan)**Head, Department of Anesthesiology and Pain Management, Combined Military Hospital, Abbottabad (Pakistan)***Consultant Anesthesiologist, Department of Anesthesiology & Pain Management, Combined Military Hospital, Rawalpindi (Pakistan)****Advisor in Anesthesiology Pakistan Army

Correspondence: Major Dr. Rehan Masroor, MBBS, MCPS, FCPS, Consultant Anesthesiologist, PAF Hospital, Mianwali (Pakistan); Cell: 0345-5893715; E-mail: docrehan@gmail.com

ABSTRACTBackground: The supply of oxygen is a complex issue in disaster situations and snowbound mountainous areas. Innovative solutions are required for safe anesthesia practice; one such innovation is a small portable oxygen concentrator for oxygen therapy in remote austere environment. We conducted this study to ascertain the economy achieved by employing this equipment to improve functionality of a surgical unit in an austere environment.

Methods: Retrospective review of patient records and cylinder consumption from 1st October 2008 to 30th March 2009 was carried out and this data was classified as group A. While group B consisted of all the patients, who required oxygen therapy from 1st October 2009 to 30th March 2010, and were divided into sub-groups, on the basis of type of anesthesia or oxygen therapy. They were further categorized with respect to use of oxygen concentrator or oxygen cylinder for oxygen provision. The percentages of patients in these subgroups were summed to ascertain the economy achieved in the use of oxygen cylinders by comparing cylinder/patient ratio between group A and B respectively. Percentage economy achieved was then calculated.

Results: In group A cylinder/patient ratio (21/53) was ‘0.4’ as compared to (3/81) ‘0.03’ of group B. Percentage economy achieved was hence found to be (0.4/0.03%)) 1333%.

Conclusion: Use of oxygen concentrator is an innovation which is economical, easily applicable and highly recommended in remote austere environments..

Key Words: Anesthesiologist; Oxygen concentrator; Safety of equipment; Military anesthesia; Oxygen delivery systems

Citation: Masroor R, Iqbal A, Buland K, Kazi WA. Use of a portable oxygen concentrator and its effect on the overall functionality of a remote field medical unit at 3650 meters elevation. Anaesth Pain & Intensive Care 2013;17(1):45-50

diligence and ingenuity.5 Pakistan Armed Forces anesthesiologists employed in the highest battlefield of world i.e. Siachen Glaciers in Gilgit Baltistan or in parts of Tribal Areas of Khyber Pukhtunkhwa province have to provide anesthesia services in far less than ideal circumstances due to the remoteness of the areas. Austerity usually connotes a location in an underdeveloped region of the world, harsh physical environment or combat zones. Austere

46 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

portable oxygen concentrator at high altitude

conditions may occur even in the most developed countries/areas when there are constraints in the delivery of care such as loss of basic infrastructure, degraded communications, and movement due to natural or manmade disasters.6 Limited medical supplies, especially of pressurized oxygen cylinders can put any healthcare provider under stress in such circumstances. Transport of oxygen cylinders across snow bound peaks is difficult and carriage by helicopters impossible due to its associated hazards. Supply of oxygen becomes even more complex in the war like disaster situations.7 Initial solutions for forward medical teams should include carrying limited amounts of tank gaseous oxygen and using small portable oxygen concentrators. This study was carried out to ascertain the efficacy of the portable oxygen concentrator and its effect on overall functionality of a remote surgical set up.

METHODOLOGYThis study was based on the practical experience of the anesthesiologists employed in an Independent Mobile Surgical Team (MST), which is located at an approximate height of 3650 meters (11000 feet) in northern areas of Pakistan. Approximately 12,000–15,000 people are dependent upon this MST for every type of surgical and medical needs. It remains snowbound for about 6-7 months every year and the supplies reach here only by helicopters. Therefore, all the stores (drugs and pre-filled pressurized O2 cylinders etc.) have to be dumped there during summers. Therefore, one has to be extremely cautious in the use of this limited resource. Electric supply is available at our location all the year, from a hydropower plant and high output diesel generators.We carried out a review of available record of all medical and surgical cases treated in MST during the previous two years and evolved following two strategies:1. To employ neuraxial and regional anesthesia

techniques wherever possible2. To procure an O2 concentrator to confine use of

O2 cylinders The O2 concentrator (DeVilbiss®) was procured and was commissioned in September 2009. As it only requires constant electricity supply and uses atmospheric air as raw material, there is no running cost or logistics required for its continuous use. This study was carried out to ascertain the economy achieved by employing it and its impact on overall functionality of MST. Formal permission to carry out this study was obtained from the Advisor in Anesthesiology, the approval of Ethics Committee of the hospital and informed consent from the patients was also obtained for this study. Due to high altitude location of MST, every patient

undergoing surgery, under any kind of anesthesia technique required supplemental O2 therapy peri - and postoperatively. The standard anesthesia technique (general/regional/neuroaxial etc) with basic monitoring (pulse oximetry (SpO2), non-invasive blood pressure (NIBP) measurement, temperature and Electrocardiography (ECG) recording) was applied in all patients, who required anesthesia care. Supplemental O2 therapy to every patient was provided through facemask from O2 cylinders or portable O2 concentrator. A quasi experimental study was carried out form 1st October 2008 to 30th March 2010 to ascertain the efficacy of use of O2 concentrator in our set up. All the patients requiring O2 therapy during the above-mentioned period were included in the study selected by non-probability convenient sampling technique. The patients were divided into two main groups namely Group A (Cylinder Group) and B (Concentrator Group). Group A (Cylinder Group) (n=53) comprised of all patients, regardless of the age and gender, who required O2 therapy for any reason from 1 October 2008 to 30 March 2009. The data (sex, age, weight and height) were collected retrospectively from patient records. All the patients in group A were provided O2 through O2 cylinders. The number of cylinders consumed was also determined from the ledger record. Group B (Concentrator Group) (n=81) included patients, of all age groups and both the sexes who required O2 therapy for any. Their age, sex, weight and height were recorded and the patients were then categorized into two categories based upon the method used to provide O2 i.e. via O2 concentrator or cylinders. Cylinder consumption during period from 1 October 2009 to 30 March 2010, was then determined from the ledger record to calculate cylinder/patient ratio. Statistical Analysis All the data collected were entered into IBM SPSS v19.0® and simple comparative analysis was carried out by comparing the percentages of patients between group A and B with respect to use of O2 concentrator vs. O2 cylinder. The assessment of the economy achieved in the use of O2 cylinders was done by comparing the cylinder/patient ratio of group A with that of group B. Percentage economy achieved was then calculated.

RESULTSPatient Demography: In group A, male to female ratio was 8.8:1 whereas it was 9:1 in group B. Mean age of the patients was 37.47 ± 5.19 years and 36.34 ± 4.69 years in group A and B respectively. Mean height of the patients in group A was 170 ± 6.40 cm as compared to 171 ± 5.73 cm in group B. Mean weight of group A

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 47

original article

patients was 68 ± 4.20 kg while it was 70 ± 3.70 kg in group B. Group A: All 53(100%) patients were provided O2 therapy through O2 cylinders, whenever required because no O2 concentrator was available at that time. Group B: The patients in concentrator group were divided into following sub-groups on the basis of posthoc analysis. Sub-group I (n= 9) included patients who were given neuraxial (spinal/ epidural) anesthesia for non gynaecological surgery. Sub-group II (n= 16) consisted of patients who underwent surgery under regional anesthesia (brachial plexus block/axillary block/popliteal block/bier’s block etc) while sub-group III patients (n= 13) were operated under local infiltration anesthesia for minor surgeries. Sub-group IV (n= 5) consisted of female patients who were given spinal anesthesia for the caesarean section, sub-group V (n= 15) included patients who were given dissociative anesthesia (ketamine with sedation) for surgeries like change of dressing, manipulation of fractured limbs/fingers etc. Sub-group VI (n=2) had patients who underwent emergency laparotomy under general anesthesia whereas sub-group VII (n=21) included patients who required O2 therapy for treatment of high altitude diseases (acute mountain sickness, high altitude cerebral edema and high altitude pulmonary edema) and respiratory tract infections (moderate to severe pneumonia etc). Details of Group B (Concentrator group) patients (number/percentages) in each sub-group requiring O2 through O2 concentrator vs cylinder O2 supply is shown in Table 1. Two patients of sub-group V and two of sub-group VI (total= 4, 4.93%) required general anesthesia, therefore cylinder O2 supply was utilized in them. In group B, 95.07 % patients (n=77) requiring minor to major surgery were provided O2 therapy with O2 concentrator and only 4.93% patients

(n=4), who required general/dissociative anesthesia consumed cylinder O2 supply (Table 1). Cylinder/Patient Ratio and Economy Achieved: The use of O2 concentrator proved extremely useful for our remote set up and enhanced its functional capability by manifold. In total three (E Type) O2 cylinders were utilized by our set up in taking care of eighty one patients (n=81) of group B giving cylinder/patient ratio (3/81) “0.03”. While last year twenty one (E type) O2 cylinders had been consumed during the same period in taking care of fifty three patients (n=53) of group A , hence cylinder/patient ratio (21/53) was found to be “0.4” (Table 2). Comparing cylinder/patient ratios of both the groups, percentage economy achieved was calculated to be (0.4/0.03%) 1333% (Table 2). Improvement in Functionality: Due to the availability of the extra gas supply and option to provide O2 through O2 concentrator during the surgeries requiring loco-regional anesthesia, overall functionality of the

Table 1: Comparison of different sub-groups of group B patients with respect to use of source of oxygen supply for O2 supply from 1st October 2009 to 30 March 2010. 95.07% patients were provided O2 through O2 concentrator while only 4.93% used cylinder oxygen supply.

Group B(sub-groups) Type of patients & anesthesia

No. of patients

(n)

O2 Concentrator Used*n (%)

O2 Cylinder Used++

n (%)

Sub-group I Non-gynecological surgery under neuraxial anesthesia 9 9 (11.11) -

Sub-group II Limb surgery under regional anesthesia 16 16 (19.75) -

Sub-group III Surgery under local infiltration anesthesia 13 13 (16.01) -

Sub-group IV Obstetric surgery under neuraxial anesthesia 5 5 (6.17) -

Sub-group V Minor surgery under dissociative (ketamine) anesthesia 15 13 (16.04) 2 (2.46)

Sub-group VI Surgery under general anesthesia 2 - 2 (2.46)

Sub-group VII Patients with medical or high altitude diseases 21 21 (25.92) -

Total 81 77 (95.07) 4 (4.93)*O2 concentrator was used to give supplemental O2++

O2 cylinder was used to provide O2 through anaesthesia machine.

Table 2: Comparison of consumption states of O2 Cylinders with number of patients requiring O2 therapy in group A and B. Table shows considerable economy achieved in the group B patients due to the use of O2 concentrators.

Group/Period

No of Patients requiring

O2 Therapy (n)

Consumption of O2

Cylinders (Numbers)

Cylinder/Patient Ratio

Percentage Economy Achieved

Group A (from 01 October 2008 to 30 March 2009)

53 21 [21/53] 0.4

1333%Group B (from 01 October 2009 to 30 Mar 2010)

81 3 [3/81] 0.03

48 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

portable oxygen concentrator at high altitude

set up improved manifold as evident by increase in the number of patients who were operated/ treated providing O2 therapy during 1st October 2009 to 30th March 2010.

DISCUSSIONThe readiness of a military anesthesiologist for battle conditions must go beyond wearing uniform or being combat fit. True medical readiness implies that the anesthesiologists possess the skills and knowledge to provide anesthesia for any mission, anytime, anywhere.8 To achieve this goal the anesthesiologist should be well conversant with the techniques that are “field friendly”, requiring minimal logistical support while maintaining safety and providing quality anesthesia and analgesia.9 The main problems which hinder the provision of quality care to any casualty in an austere environment are inadequate equipment, deficient or unavailability of pre-filled pressurized O2 cylinders which are usually not transported by the air services, lack of facilities for equipment repair and hostile and adverse climatic conditions, inadequate or inappropriate accommodation, deficiency of blood and its products and transfusion facilities, inadequate monitoring equipment, delay in receiving the casualties due to inadequate or inappropriate evacuation facilities in unexpected or difficult terrain and loss of the golden hours and full stomach patients.10 To allow safe surgery, intensive care and anesthesia of an acceptable standard in an austere environment there are some essential

business as a result of the cumbersome nature of the cylinders and has its own hazards.5 Roberts MJ et al have categorically stated that reliance on pressurized O2 cylinders is not entirely consistent with self sufficiency in many austere settings11 while Gawande A et al have suggested initial solutions for forward medical teams which include carrying limited amounts of tank gaseous O2 and using small, off-the-shelf, home-use portable O2 concentrators.12

Due to its location and the mission assigned to it, our MST is peculiar. There is no road link available during the winters, so medical supplies, especially the medical gas cylinders, have always been a source of concern. To remain fully functional medical facility, a judicious use as well as conservation of resources is needed. Cylinders do provide 100% O2 but are available in limited quantity, so there is always a possibility of shortage anytime but especially during the winters when replenishment is impossible. Remote and austere settings can pose significant challenges but choosing the right equipment, ingenuity, and sound professional skills can considerably improve the standard of care.We rationalized the provision of general anesthesia and often successfully performed surgeries under neuraxial and regional anesthesia, whenever possible, which is consistent with the recent evidence. Many studies have shown, despite differences of opinion, regional anesthesia to be more ‘field friendly’ than general anesthesia.7,13-15 There are numerous regional anaesthetic techniques which can be used in the field or field like circumstances e.g. in disasters, mass causalities or in austere environment.9,14 These vary from topical applications or simple infiltration of local anaesthetics to major nerve conduction blocks or neuraxial blocks.8,14

Mechanism of O2 concentrator: O2 concentrators which use the principle of molecular sieve provide 93 ± 3% O2 by separating the atmospheric air containing 21 % O2 and 79% nitrogen. Nitrogen is adsorbed on aluminium silicate containing filters (Zeolite meshwork) through pressure swing adsorption (PSA) and almost pure O2 is delivered either at low or high flow and pressure for medical use.4,16 Comparison of some of the characteristics of the O2 concentrator and O2 cylinder is shown in Table 3, highlighting suitability of the O2 concentrator in disaster/warlike austere situations. Many studies have underscored the application of the O2 concentrator in disasters and mass causality situations where all the infrastructure had been damaged due to natural disasters or war like situations.17,18 There are reports showing successful use of O2 concentrators in mass causalities due the earthquakes in Turkey, Iran and Pakistan; in tsunami affected areas of Indonesia; and hurricane Allison and Katrina afflicted areas of Houstan, Texas

Following are essential requirements for providing standard anesthesia and surgical care in field facing austere environments;l Secure shelter at safe locationlMotivated doctors, paramedical and ancillary stafflAmple supply of antibiotics, resuscitative medicines and dressing

materialslSatisfactory supply of electricity and arrangements of heating lAvailability of robust and quality surgical and anesthetic equipment

and monitorslAdequate supply of clean waterlDependable medical gas supply

Box 1: Essential requirements for providing standard anesthesia and surgical care in field facing austere environments

requirements which are shown in Box 1.One item which deserves special attention because of its large logistic burden and importance is O2. Venticinque SG et al in their recently published article have described O2 as “Green Gold” and have opined that using as little “stuff” as possible and making use of all that you have, are self-evident principles when resources are limited and warrants little review.5 O2 conservation should be a priority because transporting gaseous O2 is difficult

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 49

original article

and New Orleans.19-22 So much so, in some cases these concentrators had been successfully utilized for provision of general anesthesia where maintenance of anesthesia was done intravenously with midazolam/thiopentone sodium and ketamine and respiratory support was provided to the paralyzed patient through Ambu® bag attached to endotracheal tube whereas O2 was supplied by O2 concentrator.7, 9, 23 Recently, an O2 concentrator with the capability to compress O2 into a cylinder has been developed (Invacare corporation, Elyria, OH; http://www.invacare.com).24 This can give an anesthesiologist working in austere environment more options to provide standard level of care without worrying about the austerity and scarcity of medical gas supply.The analysis of these experiences when extrapolated to our setting provided us ostensibly feasible option and has proved that way as well on the basis of our research. The availability of this equipment has relieved us of many apprehensions and enabled us to achieve a better standard of care. The economy achieved is been remarkable (1333%). The conservation of this precious resource has enabled us to undertake more and more surgeries at own location hence decreasing the evacuations to base hospitals, hence enhancing the functional capability of this set up by manifold. This has also decreased the demand for emergency aero-medical evacuations through helicopters, thereby minimizing the burden on the aviation set up of the area resultantly conserving the vital assets. Recommendations: On the basis of above, following are highly recommended:

1. O2 concentrator should be an essential part of equipment inventory for medical set ups meant for the remote areas and every emergency set up to be deployed in case of disaster situations. It will enable many clinicians to provide much improved standard of care in the field/operational settings

2. Anesthesiologists should have adequate training in the techniques of regional anesthesia and taught to employ these useful techniques to maximum during mass disaster situations or in austere environment

Limitations: Following limitations of my study are identified.1. The study compared a retrospective data group

with a prospective data group, this could have affected the results.

2. The anesthesiologist expertise in different regional anesthesia techniques can be a significant factor in the outcome of the study. So this has to be kept in mind.

CONCLUSIONWar and other disasters, natural or manmade, will inevitably result in ailment and injury. The clinical specialists in warlike situations or disaster zones will always be challenged to provide advanced physiological support to preserve human life in these conditions. Given the mobility and modularity of modern medical systems, the ability to provide highest standard of care in the most austere circumstances has become not only a reality and periodic necessity, but an expectation. To discharge this responsibility in a befitting way,

Table 3: Comparison of the characteristics of Oxygen cylinders and oxygen concentrators 26, 27, 28

Characteristics Oxygen Concentrators* Oxygen Cylinders

Capital cost Not Much on portable selected models High when regulator and flow-meter costs included

Running cost Low if power is inexpensive High if power is expensive High, particularly if leakage is significant

Ease of use No considerable training required Some training requiredReliability Good GoodPhysical robustness Good Good

Regular maintenance Not much (only air filter has to be changed after some duration) Needed

Technical repairs Needed Needed (e.g. for regulators, to minimize leakage)Electricity Needed Not neededContinuity of O2 delivery Good as long as power is available Liable to run outPortability Very Good Poor for large cylinders

Supply systemOnce only Ordering neededOnce only Transport needed Minimal Logistical arrangements required

Timely Ordering neededTransport neededLogistical arrangements for safe collection required (especially in remote areas)

* Portable O2 Concentrator supplying 5-6 L/Min O2

50 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

portable oxygen concentrator at high altitude

1. Olasinde AA, Oluwadiya KS. Anesthesia Practice in a Hospital, developing countries: An 18 month’s experience. The Intl J Third World Medicine 2005; 3; 1-4. (Free Full Text)

2. Roberts P, Patterns of injury in military operations. Current Anesthesia & Critical Care, Volume 13, Issue 5, October 2002, Pages 243-248. (Online Access)

3. Bonanno FG, Ketamine in war tropical surgery. Injury 2002; 33: 323 – 27. (Medline)

4. Litch JA, Bishop RA. Oxygen concentrators for the delivery of supplemental oxygen in remote high-altitude areas. Wilderness Environ Med 2000; 11: 189-91. (Medline)

5. Venticinque SG, Grathwohl KW. Critical care in the austere environment: Providing exceptional care in unusual places. Crit Care Med 2008; 36: S284-92. (Medline)

6. Grathwohl KW, Venticinque SG. Organizational characteristics of the austere intensive care unit: The evolution of military trauma and critical care medicine; applications for civilian medical care systems. Crit Care Med 2008; 36: S275-83. (Medline)

7. Dobson M, Peel D, Khallaf N. Field trial of oxygen concentrators in upper Egypt. Lancet 1996; 347: 1597-99. (Medline)

8. Grande CM, Baskett PJ, Donchine Y, Wiener M., Bernhard, WN, Trauma anesthesia for disasters. Anything, anytime, anywhere. Crit Care Clin 1991; 7: 339 – 61. (Medline)

9. McGuire NM, Monitoring in the Field. Br J Anaes 2006; 97: 46-56. (Medline) (Free Full Text)

10. Paix BR, Capps R, Neumeister G, Semple T. Anesthesia in disaster zone: a report on the experience of an Australian medical team in Banda Aceh following the ‘Boxing Day Tsunami’. Anaesth Intensive Care 2005; 33: 629 –34. (Medline)

11. Roberts MJ, Salmon JB, Sadler PJ: The provision if intensive care and high dependency care in the field. J R Army Med Corps 2000; 146: 99–103. (Abstract) (Free Full Text)

12. Gawande A: Casualties of war - military care for the wounded from Iraq and Afghanistan. N Engl J Med 2004; 351:2471–475. (Medline) (Free Full Text)

13. Greengrass RA, Regional anesthesia for ambulatory surgery. Anesthesiol Clin North America 2000; 18: 341 –53. (Medline)

14. Klein SM, Evans H, Nielsen KC, Tucker MS, Warner DS, Steele SM. Peripheral nerve block techniques for ambulatory surgery. Anaesth Analg 2005; 101: 1663-75. (Medline) (Free Full Text)

15. Charuluxananan S. Bunburaphong P, Tuchinda L, vorapaluk P, Kyokong O. Anesthesia for Indian Ocean Tsunami –affected patients at a southern Thailand provincial hospital. Acta Anaesthesiol Scand 2006; 50: 320 –23. (Medline)

16. Dobson MB. Oxygen concentrators for the smaller hospital — a review. Trop Doct 1992; 22: 56-8. (Medline)

17. Schneider G. Oxygen supply in rural Africa: a personal experience. Int J Tuberc Lung Dis 2001; 5: 524-26. (Medline)

18. Shrestha BM, Singh BB, Gautam MP, Chand MB. The oxygen concentrator is a suitable alternative to oxygen cylinders in Nepal. Can J Anaesth 2002; 49: 8-12. (Medline)

19. Suzuki T, Difficulty in oxygen procurement in conflict or disaster areas. Masui 2009; 58: 508-13. (Medline)

20. Bar-Dayan Y, Leiba A, Beard P, et al: A multidisciplinary field hospital as a substitute for medical hospital care in the aftermath of an earthquake: The experience of the Israeli

Defense Forces Field Hospital in Duzce, Turkey 1999. Prehosp Disaster Med 2005; 20: 103–06. (Medline)

21. Owens P, Forgione A, Briggs S: Challenges of international disaster relief: Use of a deployable rapid assembly shelter and surgical hospital. Disaster Manag Response 2005; 3: 11–16. (Medline)

22. D’Amore AR, Hardin CK: Air Force Expeditionary Medical Support Unit at the Houston floods: Use of a military model in civilian disaster response. Mil Med 2005; 170:103–108. (Medline)

23. Metcalfe NH, Military influence upon the development of anesthesia from the American Civil War (1861 – 1865) to the outbreak of the First World War. Anesthesia 2005; 60: 1213. (Medline)

24. McCormick BA, Eltringham RJ. Anesthesia equipment for resource-poor environments. Anesthesia 2007; 62: 54–60. (Medline)

25. Carter JA, Baskett PJF, Simpson PJ. The ‘Permox’ oxygen concentrator: its mode of action, performance and potential application. Anesthesia 1985; 40: 560-65. (Medline)

26. Howie SR, Hill SE, Peel D, Sanneh M, Njie M, Hill PC, et al. Beyond good intentions: lessons on equipment donation from an African hospital. Bull World Health Organ 2008; 86: 52-6. (Medline) (Free Full Text)

27. Wilson PM. Concentrators: portable and transportable. In: Portable oxygen: a user’s perspective. Available online at http://www.portableoxygen.org/july.html. (Online Access)

28. Implementation of an oxygen concentrator system in district hospital paediatric wards throughout Malawi. Bulletin of the World Health Organization 2008; 86: 321-416. (Online Access)

REFERENCES

there is requirement of innovation, improvisation and judicious use of available resources in operational situations. Use of O2 concentrator is one such measure which is evidence based, highly recommended and time tested. It provides very economical and easily applicable solution to O2 shortage in resource limited

austere environments.

Competing interests: We declare no competing financial, professional or personal interests that might have influenced the performance or presentation of this work described in this manuscript.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 51

oRIGINAL ARTIcLe

A retrospective seven years audit of mode of deliveries in a tertiary care university hospital of TurkeyBerrin Gunaydin, MD, PhD*, Kadir Kaya, MD*

*Professor of Anesthesiology Department of Anesthesiology, Gazi University School of Medicine, Ankara (Turkey)

Correspondence: Prof. Berrin Gunaydin, Division of Obstetric Anesthesia, Gazi University School of Medicine, Besevler 06500, Ankara (Turkey); Phone: +90 312 202 53 18; Fax: +90 312 489 21 19; E-mail: gunaydin@gazi.edu.tr

ABSTRACT Aim: We aimed to present an audit on delivery rates and obstetric anesthesia techniques at Gazi University Hospital in Turkey over a period of seven years to compare it with national or international standards.Materials and methods: Annual rate of different modes of deliveries (vaginal or caesarean section) and obstetric anesthesia techniques were retrospectively audited over seven years. Results: Our audit shows a progressive rise in the rate of caesarean section (CS) from 33.72% in 2002, to 57.41% in 2008 over vaginal deliveries. There is also an increased use of regional anesthesia for CS. While the practice of epidural anesthesia for CS has decreased, utilization of CSE and spinal anesthesia has increased over 7 years. Conclusion: We conclude that over the last 7 years, the rate of CS, spinal anesthesia for elective CS and neuraxial analgesia for labour in our unit has progressively increased.Key words: Obstetrics; Caesarean section; Vaginal delivery; Regional techniques; Spinal analgesia; Epidural; Combined spinal epiduralCitation: Gunaydin B, Kaya K. A retrospective seven years audit of mode of deliveries in a tertiary care university hospital of Turkey. Anaesth Pain & Intensive Care 2013;17(1):51-54*This paper was presented in part at the 40th Annual Meeting of SOAP held in Chicago (USA), 2008.

INTRODUCTIONThe caesarean section (CS) rate has increased the world over during the previous few decades. In the United States it has exceeded 24% and anesthesia was responsible for approximately 3-12% of all maternal deaths in that country from 1979 to 1990.1 The report on confidential enquiries of maternal deaths over 50 years (1952-2002) confirmed the remarkable decline in the anesthesia-related maternal mortality.2 This decline has been attributed to the increased use of regional anesthesia, improvement in anesthetic technique and introduction of H2 receptor antagonists. Successive reports indicated that anesthesia related maternal deaths mainly associated with general anesthesia were due to difficult intubation resulting in maternal hypoxia and/or to pulmonary aspiration of gastric contents.3 Therefore, utilization of general anesthesia for CS has progressively declined and now it is limited only to specific situations where regional anesthesia is contraindicated, refused by the mother or not appropriate to conduct because of time

factor.3

A progressive rise in the caesarean delivery rate has been observed worldwide since 1970.4 Therefore, the need to implement safe anesthesia techniques for operative deliveries has risen as well. While safe anesthetic practice is a norm in the developed countries, it still remains unsatisfactory in many of the developing countries. We aimed to investigate obstetric anesthesia database for rate of vaginal and caesarean deliveries, and for choice of anesthesia techniques for these deliveries in a tertiary care university hospital of Turkey in order to match it with the standards of developed countries.

METHODOLOGYAfter approval of research ethics committee of Gazi University, following data were collected on deliveries carried out at Gazi University, Faculty of Medicine, Ankara (Turkey) from 1st January 2002 to 31st

52 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

audit of mode of deliveries and practice of obstetric anesthesia

December of 2008:1. Annual rate of vaginal and caesarean deliveries2. Anesthesia technique (general or regional) used and

type of regional anesthesia (epidural / combined spinal epidural (CSE) or spinal).

The data were audited retrospectively and presented as number “n” or percentage (%).

RESULTS Our audit showed a progressive rise in the rate of CS (from 2002-2006 and then decline from 2006-2008). The rates of caesarean deliveries were 33.72% (401/1189), 54.10% (652/1205), 59.70% (815/1365), 60.03% (1065/1774), 70.76% (1411/1994), 65.99% (1448/2194) and 57.41% (1490/2595) from the beginning of 2002 till the end of 2008 respectively (Figure 1).

There was increase in utilization of regional anesthesia with a steady decline in general anesthesia. Rate of regional versus general anesthesia for caesarean deliveries were around 58/42% (231/401), 57/43% (282/652), 55/45% (449/815), 57/43% (609/1065), 76/24% (1024/1411), 89/11% (1294/1448) and 97/3% (1439/1490) from 2002 to 2008, respectively (Figure 2).

Regarding the types of regional anesthesia for CS, rates of epidural anesthesia has declined, whereas rates of CSE and of spinal anesthesia have risen throughout the audited years. Neuraxial analgesia for labour was started in 2003 and it reached to 13.6% in 2008 (Figure 3). During the audit period, 3 mothers died because of breast cancer which was diagnosed during pregnancy.

DISCUSSION Our retrospective audit for a period of seven years showed a gradual increase in the rate of CS as well as in the rate of regional anesthesia for CS compared to general anesthesia. Although very unevenly distributed, 15% of births worldwide occur by CS. Latin America and the Caribbean show the highest rate (29.2%), and Africa shows the lowest (3.5%).3 In developed countries, the proportion of caesarean births is 21.1% whereas in least developed countries only 2% of deliveries are by CS. The analysis suggests a strong inverse association between CS rates and maternal, infant and neonatal mortality in countries with high mortality levels.3 Although, rate of vaginal deliveries has declined compared to CS rate, use of neuraxial analgesia for labour has increased. Since 2002, almost all of our uncomplicated parturients requesting regional analgesia for labour have been receiving CSE and elective CS operations have been performed under single shot spinal anesthesia. During the audit period at our institution, segmental epidural anesthesia was provided with 20-25 ml of 0.5% bupivacaine with fentanyl 50 μg through epidural catheter to achieve T4 level of block for CS. The CSE was performed with 10 mg of 0.5% hyperbaric bupivacaine with 20 μg of fentanyl intrathecally followed by epidural top up boluses if necessary.5 Single shot spinal anesthesia was provided with 12 mg of 0.5% hyperbaric bupivacaine with 10 μg of fentanyl and 100 μg of morphine.6 Neuraxial analgesia for labour was performed with

Figure 2: Choice of anesthesia technique (regional or general) for cesarean delivery over seven years.

Figure 3: Rate of neuraxial labour analgesia over seven years.

Figure 1: Rate of delivery (cesarean or vaginal) over seven years.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 53

original article

either 7 ml of 0.1% bupivacaine with 50 μg of fentanyl through the epidural catheter, or CSE with 20 μg of intrathecal fentanyl without bupivacaine. Both epidural and CSE techniques were maintained by patient controlled epidural analgesia (PCEA) including 0.1% bupivacaine with 2 μg/ml of fentanyl (5 ml bolus on demand with 10 minute lock-out).7 The CSE technique has been provided using intrathecal 0.5% bupivacaine 2.5 mg with fentanyl 15 μg followed by PCEA with 0.0625% bupivacaine with fentanyl 2 μg/ml, set to deliver 10 ml/h basal infusion, 5 ml bolus on demand and 10 min lock-out.8 The National Sentinel Caesaraen Section Audit (NSCSA) reported that CS rates increased from 9% of deliveries in 1980 to 21% in 2001 with similar increase in many developed countries.9 The reason for this increase in CS rate in our unit is probably due to surgeons’ and/or patients’ preferences. The choice of anesthetic technique is a cause of concern due to the anesthesia-related deaths and the associated risks and complications associated with poor anesthesia technique.2 Based on our 7-year retrospective audit, we have shown the distribution of anesthesia technique for CS in a tertiary university hospital for better understanding of changing protocols and regulations to administer safe obstetric anesthetic care.In the past, many anesthesiologists were mainly trained in general anesthesia for CS.10 Some might have finished anesthesia training without ever seeing a CS under spinal anesthesia.10 We also used to perform more of the CS in our unit under general anesthesia. However, over the period of time, epidural anesthesia for elective caesarean deliveries became popular with the understanding and cooperation of obstetricians in our unit. Soon after its introduction in our unit, both the acceptance level and the experience of anesthesiologists and the obstetricians rose for regional techniques, including epidural anesthesia for CS, CSE and/or single shot spinal anesthesia. Several surveys on obstetric anesthesia in USA have shown that there is a significant decline in use of

general anesthesia for CS. According to a recent report, the rate of general anesthesia for CS was 3.6% among the parturients delivered at Brigham and Women’s Hospital which has an annual delivery rate of over 10,000.11 In the beginning of our audit, the rate of general anesthesia for elective CS was 42.39% and it declined to 3.43% by 2008. 96.57% of the parturients had regional anesthesia for CS in 2008, where most of them received spinal anesthesia. According to health statistics of Republic of Turkey, the number of annual births per thousand people is 1479.12 Most of these deliveries are assisted by a physician (46.7%) or by a trained midwife/nurse (36.3%). While most of them are performed in a health institution (78.5%), home deliveries are around 21.5%.12 There are no midwives in Gazi University hospital and almost all vaginal deliveries are always performed by trained obstetricians. Regarding anesthesia technique, we have successfully switched from general anesthesia to spinal anesthesia for elective CS over the previous seven years. Limitations of the study: The limitation of the present study is the lack of large scale audits covering whole of the country for comparison. Only a recent national retrospective audit was conducted for a 10-year period (2000-2010) at Uludag University, Bursa (Turkey).13 In that survey, the rates for CS and vaginal birth were 50.1% and 49.9% respectively. The CS rate was 41.88% in 2000 but it increased to 54.12% in 2010, which was similar to our CS rate (≅57% in 2008).13 Therefore, we plan to re-audit last five years not only to improve obstetric anesthesia practice in our facility to meet worldwide standards but also to acquire fresh information for further comparison.

CONCLUSIONIn conclusion, we have demonstrated an increase in the rate of CS and the utilization of regional anesthesia in a tertiary care university hospital in Turkey based on 7 years of retrospective audit. This finding is similar to that observed in most of the developed countries.

54 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

audit of mode of deliveries and practice of obstetric anesthesia

1. Kuczkowski KM. Anesthesia for cesarean section. In: Chestnut DH, ed. Obstetric Anesthesia Principles and Practice. 3rd ed. Philadelphia: Elsevier Mosby; 2004: 421-446.

2. Ngan Kee WD. Report on confidential enquiries into maternal deaths: 50 years of closing the loop. Br J Anaesth 2005;94:413-16. [Medline] [Free Full Article]

3. Pang D, O’Sullivan G. Anesthesia and analgesia in labour. Obstet Gynaecol Rep Med 2008;18:87-92. [Medline]

4. Analysis global, regional and national estimates. Paediatr Perinat Epidemiol 2007;21:98-113. [Medline]

5. Gunaydin B, Tan ED. Intrathecal hyperbaric bupivacaine and ropivacaine with fentanyl for elective caesarean section. J Matern Fetal Neonatal Med 2010;23(12):1481-6. [Medline] doi: 10.3109/14767051003678051.

6. Faydaci F, Gunaydin B. Different preloading protocols with constant ephedrine infusion in the prevention of hypotension for elective caesarean section under spinal anesthesia. Acta Anaesthesiol Belg 2011;65:5-10. [Medline]

7. Sezer AO, Gunaydin B. Efficacy of patient controlled epidural analgesia (PCEA) after initiation with epidural or combined spinal-epidural analgesia. Int J Obstet Anesth 2007;16;226-230. [Medline]

8. Gunaydin B. Obstetric pain and its management in the perinatal period: What do we need to know?. In: International Textbook of Obstetric Anesthesia and Perinatal Medicine Principles and Practice, Kuczkowski KM, Drobnik L (eds), Warsaw: Medmedia, 2010; p34-39.

9. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists Clinical

Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report. London: RCOG Press, 2001.

10. Oyston J. Obstetrical anaesthesia in Ontario. Can J Anaesth 1995;42:1117-25. [Medline]

11. Palanisamy A, Mitani AA, Tsen LC. General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update. Int J Obstet Anesth. 2011;20:10-16. [Medline] doi: 10.1016/j.ijoa.2010.07.002

12. Reproductive Health Programme Turkey. National Maternal Mortality Study 2005 Key Findings.

13. Çetinkaya Demir B, Ocakoğlu G, Özerkan K, Orhan A, Cengiz C. Cesarean delivery rates and changing indications in our clinic between 200-2010. Uludag Univ Tip Fak Derg 2012;38:123-7.

REFERENCES

‘My Most Memorable Patient’®

A young, physically strong male patient of ASA 1 reported to operating rooms to get removed three of his small lipomas, which were scattered between his anterior abdominal wall and the lateral side of the right thigh. Routine monitors were attached and all his parameters were noted to be within normal limits. General anesthesia (GA) was induced in a routine manner and an LMA was inserted. Inj. pethidine was used to provide analgesia. Everything seemed to be going smooth as planned. The procedure was a short one and there was no hurry. The surgical excision was underway, when about 10 minutes after the induction of GA, the cardiac monitor sounded alarm. A reading showed high BP. The reading was repeated without change. Assuming inadequate analgesia, a second dose of inj. pethidine was given and the depth of anesthesia was increased. After a few minutes BP was measured by the manual (stat) method. It was even still higher. The circuit and the endotracheal tube were rechecked and no fault was detected. The cause of his hypertension could not be found. Just then the surgeon informed that he had finished the surgery. The gases were turned off and 100% oxygen was started. A few minutes later, LMA was removed and the patient was shifted to the PACU. It was hoped that with the cessation of the surgical stimulus, his high BP would settle down, but the increased BP failed to get lowered despite all conservative measures. The patient started to desaturate and developed severe tachycardia. Reintubation was done to provide 100% oxygen by mechanical ventilation. Pink frothy fluid filled the tube and had to be suctioned repeatedly. The next reading was recorded at 220/130 mmHg. The patient was transferred to the ICU and ventilated; CT scan was done on an emergent basis while the patient was on ventilator. A small suprarenal mass was found, suspected to be a pheochromocytoma. Relevant investigations were ordered and medical treatment was provided. The next day after being stabilized, the patient was transferred to a better equipped, central referral hospital for surgical removal of his pheochromocytoma. Patient visited us one month later for follow-up in a perfect condition. On inquiring, he still denied having any episode of high BP or related symptoms any time in his life. The stress of anesthesia and surgery had somehow, provocated a silent tumor in this asymptomatic young man, which precipitated an episode of acute rise of BP and pulmonary edema.

Dr. Nabil EstemalikConsultant /HoD Anesthesiology, Oasis Hospital,United Arab Emirates

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 55

oRIGINAL ARTIcLe

A prospective, randomized, double-blind, comparative study of the efficacy of intravenous ondansetron and palonosetron for prevention of postoperative nausea and vomitingBijaya Kumar Shadangi1, Jitendra Agrawal2, Rabindra Pandey3, Arvind Kumar4, Sanjay Jain5, Rakhi Mittal6, H K Chorasia7

1, 4 Consultant, Department of Anesthesiology, Medanta-Medicity, Gurgaon, Sector-38, Delhi-NCR (India)3 Associate professor, Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi (India)2 Assistant professor ,5 Resident,6 Senior resident,7 Associate professor, Department of Anesthesiology, GR Medical College, Gwalior (India)

Correspondence: Dr.Bijaya kumar shadangi, Flat no 107, Atulya Apartments, Sector-18B, Dwarka, New Delhi-110078 (India); Phone: 91-9873422769; E-mail:drbijayakumars@gmail.com.

ABSTRACT Background: Palonosetron is a second generation 5-Hydroxytryptamine-3 receptor antagonist with longer half-life and higher receptor binding affinity than Ondansetron.

Aims & objective: To assess the efficacy and safety profile of intravenous palonosetron cpompared to the ondansetron for prevention of post-operative nausea and vomiting (PONV) under general anesthesia.

Methodology: A prospective, randomized, placebo-controlled, double-blind study was conducted in 90 patients aged 20-60 years, undergoing major surgeries. Group I (n=30) received placebo injection; Group II (n=30) received inj. ondansetron 8 mg and Group III (n=30) received inj. palonosetron 0.075 mg IV. In the operating room, the study drugs were given IV in equal volume of 4ml, before inducing the patients. In postoperative period each patient was observed for retching, nausea and/or vomiting at 30 min; and then at 1, 2, 6, 12 and 24 hours. Any side effects intra-operatively and post-operatively were recorded.

Results: The number of patients, who remained vomiting free in the first 24 hours after surgery was 56.6%, 80% and 86% in the placebo, Ondansetron and Palonosetron groups respectively. The difference with placebo was highly significant for ondansetron (p < 0.05), and highly significant for palonosetron (p=0.009). The difference in vomiting between Ondansetron and Palaonosetron was not significant but the incidence of nausea was significantly less common in the Palonosetron group than the Ondansetron group (16.7% vs. 43.4%, p=0.006).

Conclusion: We conclude that the second generation 5-HT3 antagonist, palonosetron is significantly more effective against PONV than ondansetron. It has a particularly more pronounced and prolonged effect on postoperative nausea.

Keywords: PONV; Ondansetron; Palonosetron; General anesthesia.

Citation: Shadangi BK, Agrawal J, Pandey R, Kumar A, Jain S. Mittal R and Chorasia. A prospective, randomized, double-blind, comparative study of the efficacy of intravenous ondansetron and palonosetron for prevention of postoperative nausea and vomiting. Anaesth Pain & Intensive Care 2013;17(1):55-58

INTRODUCTIONDespite having the better understanding knowledge about the pathophysiology of nausea and vomiting and use of more stable and effective anti-emetics like ondansetron, granisetron, the postoperative nausea / vomiting (PONV) continues to be the most disturbing

complication following surgery and anesthesia.1 The negative impact of PONV on patient’s physical, metabolic and psychological condition not only delays discharge from or cause re-admission to hospital but also decreases the confidence level in future surgery and anesthesia.

56 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

comparison of palonosetron and ondansetron in PONV

The incidence of PONV increases with definite risk factors including female gender, non-smokers, motion sickness, type and duration of surgery and use of peri-operative opioids. In addition,2- 4 patient anxieties prior to surgery, type of anesthetic medications5 and techniques also influence the incidence of PONV. With increased risk factors in a patient the chances of PONV may rise from 20% to 80%. The role of 5HT3 receptors present in the central nervous system area namely at chemoreceptor trigger zone (CTZ), cerebral cortex, vestibular system and peripherally at gastrointestinal tract, have been established in the pathogenesis of PONV. The use of 5HT3 antagonists in the control of PONV proved to be beneficial by selectively blocking these receptors.The 5HT3 antagonists like ondansetron, granisetron have been proved to be effective in preventing PONV even in the presence of several risk factors. Due to relative short duration of action (elimination half-life is less than 12 hours), most of them require repeated doses even during first 24 hours period. In spite of widely available anti-emetics not a single drug is 100% effective and combination therapy has its own side effect.7-9 Second generation 5HT3 antagonist, palonosetron was initially approved for prophylaxis of nausea and vomiting in cancer patients, as it improves the prevention of chemotherapy7 induced nausea and vomiting and proved superior to ondansetron in these patients. Because of its unique chemical structure, greater binding affinity with additional allosteric site binding property6 and a substantially longer half-life of almost 40 hours made palonosetron suitable for its use in prevention of PONV. We designed this randomized double-blind study to compare the anti-emetic efficacy of new, long acting drug palonosetron with commonly used drug ondansetron in the presence of various risk factors of PONV.

METHODOLOGYThis prospective randomized, controlled, double-blind study was carried out at Department of Anesthesiology, GR Medical College, Gwalior (India), after getting approval from institutional ethical committee. Signed informed consent form was obtained from all the participants. 90 patients of ASA grade I and II of either sex, age group 20-60 years, scheduled for major elective surgeries under general anesthesia were enrolled in the study. Randomization of the patients was carried out by coded envelop technique among three study groups and drugs were loaded in identical syringes with the code by the personnel not participating in the study.

Group I (n=30) was the control group, and the patients in it received 4 ml of normal saline IV as placebo, Group II (n=30) patients received 4 ml of inj. ondansetron IV, and Group III (n=30) patients received inj. palonosetron 0.075 mg diluted to 4 ml with normal saline given slowly IV 10 min before induction.Patients with difficulty in communicating, those prone to nausea, vomiting or motion sickness, patients on opioid analgesics or anti-emetics within 24 hours before anesthesia, requiring continuous gastric suction for 24 hours in postoperative period, patients having Mallampatti grade-II or above were excluded from study. All the patients were kept nil orally overnight and allowed oral diazepam 10 mg and pantoprazole 40 mg (a proton pump inhibitor) before bed time at the night before surgery and early morning on the day of surgery as premedicant. In the operating room an IV line was secured and standard monitoring devices were applied. Study drugs were given by slow IV injection, 10 minutes before induction of anesthesia. After standard anesthesia induction with fentanyl 2 μg/kg, thiopentone sodium 3-5 mg/kg (propofol was avoided because of its anti-emetic property) and vecuronium 0.1 mg/kg, intubation was done with a cuffed endotracheal tube. Anesthesia was maintained with isoflurane in O2 plus air mixture. Intermittent boluses of vecuronium were used for muscle relaxation and of fentanyl for analgesia. At the end of each surgical procedure residual effect of muscle relaxant was reversed with a combination of glycopyrrolate (10 μg/kg) and neostigmine (50 µg/kg). Inj. diclofenac sodium 75 mg was used intra-operatively and in the postoperative period for analgesia. After extubation and complete recovery, the patients were moved to postanesthesia care unit (PACU). In the PACU, every patient was watched and monitored for nausea, retching and vomiting at 30 min, 60 min, 2 hr, 6 hr, 12 hr and 24 hr. Any side-effects of the drugs or complications during the intra-operative and postoperative period were recorded and treated accordingly. All observed data are expressed as percetage and numbers. The incidence of nausea was assessed subjectively by intensity score, where 0=No nausea, 1=Mild nausea, 2=Moderate nausea and 3=Severe nausea.Complete drug response (R) was considered as no PONV and if no use of rescue drugs to prevent or treat the PONV. Vomiting was defined as the forceful expulsion of gastric contents from the mouth. Nausea was defined as the subjective unpleasant sensation associated with awareness of the urge to vomit. The statistical observations of the categorical variables were evaluated by using Chi square and student’s t-test for continuous variables and one-way analysis

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 57

original article

of variance (ANOVA) for comparison of mean values among study groups. The observed side-effects were analyzed with Fisher’s exact test. The observational results are expressed mainly as mean ± SD or number (%). p<0.05 was considered significant.

RESULTSThe patient characteristics including the age, gender ratio, previous history of PONV or motion sickness were comparable and the differences were not statistically significant. In our study the mean age of the patient was 41.4±12.7 (range 20-60 years) in Group-I, 36.6±10.93 (range 20-60 years) in Group-II and 39±9.68 (range 20-60 years) in Group-III. The male to female ratio was 1 in Group-I and Group-II and 1.3 in Group-III (56.6% vs. 43.3%).In our study, the incidence of complete response to prevent vomiting (no vomiting, no rescue medications) for placebo and palonosetron were 56.6% and 86.6% (p-value=0.009 highly significant), and for placebo and ondansetron were 56.6% and 80% (p-value= 0.05 significant) respectively. Vomiting free patients in ondansetron group were 80% and in palonosetron group 86.6%, which was statistically not significant at the end of 24 hours (p-value= 0.11).The overall incidence of nausea in the first 24 hours was much less in the palonosetron group than the ondansetron group (16.7% vs. 43.4%, p-value=0.006), but there was no observable significant difference between the Group-II and Group-III during the first 2 hours as far as both nausea and vomiting were concerned (Table 1).

Group IN =30

Group IIN = 30

Group IIIN = 30

p-valueI, II

p-valueI, III

p-valueII, III

30 minutes.Nausea n (%)Vomiting n (%)

10 (33.4)5 (16.7)

8 (26.7)4 (13.4)

3 (10)2 (6.7) 0.5

0.7

0.020.22

0.090.38

60 minutes.Nausea n (%)Vomiting n (%)

10 (33.4)10 (33)

4 (13.3)3 (10)

3 (10)2 (6.7)

0.060.02

0.020.009

0.680.64

120 minutes.Nausea n (%)Vomiting n (%)

17 (56.6)7 (24)

3 (10) 2 (6.7)

5 (16.7)2 (6.7)

0.00010.07

0.0010.07

0.440.99

8 hoursNausea n (%)Vomiting n (%)

25 (83.3)6 (20)

5 (16.7)1 (3.4)

5 (16.7)2 (6.7)

0.00010.04

0.00010.12

0.990.55

24 hoursNausea n (%)Vomiting (n (%)

22 (73.3)13 (43.3)

13 (43.3)6 (20)

5 (16.7)4 (13.4)

0.060.05

0.00010.009

0.0060.48

Nausea free n (%)Vomiting free n (%)

5(16.6)9 (30)

11(36.6)15 (50)

18(60)21 (70)

0.070.11

0.00050.001

0.070.11

Table 2: Significant adverse effects observed. Data presented as N(%)

Placebo(n=30)

Ondansetron(n=30)

Palonosetron(n=30)

Headache 2(6.6) 4(13.3) 2 (6.6)Dizziness 1(3.3) 0 (0) 1 (3.3)Drowsiness 2(6.6) 1 (3.3) 0 (0)

The incidence of major adverse effects, e.g. headache, drowsiness and dizziness, was comparable between all the study groups (Table 2).

DISCUSSIONIn this randomized, double-blind, phase three clinical study, we evaluated the response and efficacy of single IV dose of a new promising 5HT3 receptor antagonist, palonosetron and compared it with ondansetron for prevention of PONV.In our study, the dose selection was based on the recommendations of a previous study of single IV dose of 0.075 mg palonosetron.11 US Food and Drug Administration (FDA) approved a single dose of palonosetron 0.075 mg for preventing PONV for up to first 24 hours after the surgery.10-12 We evaluated effect of single dose of palonosetron in comparison with single IV dose of ondansetron 8 mg, as many other investigators suggested this as an optimum dose. A stratified multicenter study12 evaluated the dose response of the three different single IV doses of palonosetron and observed a linear trend in efficacy with increasing doses, with only the highest dose (0.075 mg) of palonosetron demonstrated a statistical significant

Table 1: Frequency of nausea and vomiting compared between placebo (Group -I), Ondansetron (Group-II) and Palonosetron (Group-III) and nausea and vomiting free patients.

58 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

comparison of palonosetron and ondansetron in PONV

treatment effect with complete drug response(no emesis, no rescue medication) was 43%. Another concurrent study described in the accompanying paper in the same issue of the journal showed the benefit of 0.075 mg IV doses of palonosetron in that complete drug response was 56% over first 24 hours and 70% for 24-72 hours post-operatively.11In our study during 0 to 24 hours postoperatively the complete drug response was 83.3% with palonosetron which was statistically significant. We also found that a single dose of 0.075 mg palonosetron produced a considerable decrease in the incidence and severity of nausea than ondansetron (16.7% Vs 43.3%, p=0.006) but there was no significant difference in the incidence of vomiting over 24 hours postoperatively. The findings of our study are also consistent with the findings of other previous studies,8 which showed that palonosetron is better than ondansetron at least in prevention of nausea.The safety profile of palonosetron was comparable to the drug ondansetron. Most 5HT3 antagonists exhibit side effects like headache, dizziness and drowsiness. In our study, the incidence of drowsiness and dizziness in palonosetron and ondansetron groups were 0% Vs 3.3% and 3.3% Vs 0% respectively, which was consistent with previous studies. We avoided use of N2O so as to minimize the baseline risk factors for PONV during maintenance of general anesthesia. Side effect like headache was 6.6% in palonosetron group and 13.3% in ondansetron group which was consistent with findings

of another earlier study,13 which demonstrated a frequency of headache in 6.67% in palonosetron group and 20% in ondansetron group.

Limitations and Scope of Future Studies: In order to generalize such a study, one needs to include regional anesthesia procedures, including use of neuraxial opioids. We exclusively enrolled patients who had had only general anesthesia. Further studies are required on palonosetron in larger study samples and in a wide variety of surgical procedures, especially involving high risk for PONV cases. There is also a need for more studies to ascertain the equipotency of these drugs with various other dose options and routes of administration e.g. continuous IV infusion. There is a scope of further studies using a combination of anti-emetic drugs to get optimum management of PONV in different groups of patients including extreme age groups e.g. elderly and pediatric patients.

CONCLUSION We conclude that the second generation 5-HT3 antagonist, palonosetron is significantly more effective against PONV than ondansetron. It has a particularly more pronounced and prolonged effect on postoperative nausea.

Conflict of Interest: None.

Source of Funding: None.

1. Gan TJ. Risk factors for post-operative nausea and vomiting. Anesth Analg 2006; 102: 1884-89. [Medline] [Free full text]

2. Yoon JS, Kim KM, Kim YH. The effects of amounts of intra-operative intravenous fluid administration on post-operative Nausea and Vomiting during gynaecological surgeries. Korean J .Anesthesiol.2008;55:166-170. http://dx.doi.org/10.4097/kjae.2008.55.2.166

3. Park JW, Jun JW, Lim YH, Lee SS, Yoo BH, Kim KM, et al. The comparative study to evaluate the effect of palonosetron monotherapy versus palonosetron with dexamethasone combination therapy for prevention of post-operative nausea and vomiting. Korean J Anesthesiol 2012 Oct;63(4):334-9. doi: 10.4097/kjae.2012.63.4.334. Epub 2012 Oct 12. [Free PMC Article]

4. Sweeney B P. Why does smoking protect against PONV? Br J Anaesth 2002;89(6):810-813. [Medline]

5. Onaka M, Yamamoto H. Comparison of analgesics used during balanced anesthesia on the incidence of PONV. Masui 2004 Feb;53(2):161-6. [Medline]

6. Rojas C, Stathis M, Thomas AG, Massuda

EB, Alt J, Zhang J, Rubenstein E, et al. Palonosetron exhibits unique molecular interactions with the 5HT₃ receptor. Anesth Analg 2008;107:469-479. [Medline] doi: 10.1213/ane.0b013e318172fa74.

7. Apro MS, Macciocchi A, Gridelli C. Palonosetron improves prevention of chemotherapy induced nausea and vomiting in elderly patients. J Support Oncol 2005;3(5):369-74. [Medline]

8. Moon YE, Joo J, Kim JE, Lee Y. Anti-emetic effect of ondansetron and palonosetron in thyroidectomy: a prospective, randomized, double-blind study. Br J Anaesth 2012 Mar;108(3):417-22. [Medline] doi: 10.1093/bja/aer423. Epub 2012 Jan 25.

9. Vishal Gupta. Prophylactic antiemetic therapy with ondansetron, granisetron and metoclopramide in patients undergoing laparascopic cholecystectomy under general anesthesia. The Internet Journal of Anaesthesiology. 2008, April–June, Vol 10, No. 2.

10. Tramer MR, Reynolds DJ, Moore RA, McQuay HJ. Efficacy, dose response and safety of Ondansetron in prevention of post-operative nausea and vomiting. A quantitative systematic

review of randomized placebo-controlled trials. Anesthesiology 1997;87:1277-89. [Medline]

11. Kovac AL, Eberhart L, Kotarski J, Clerici G, Apfel C; Palonosetron 04-07 Study Group. A randomized double blind study to evaluate the efficacy and safety of three different doses of palonosetron versus placebo for preventing post-operative nausea and vomiting over a 72-hour period. Anesth Analg 2008;107:439-444. [Medline] doi: 10.1213/ane.0b013e31817abcd3.

12. Candiotti KA, Kovac AL, Melson TI, Clerici G, Joo Gan T; Palonosetron 04-06 Study Group. A randomized double blind study to evaluate the efficacy and safety of three different doses of palonosetron versus placebo for preventing post-operative nausea and vomiting. Anesth Analg 2008;107:445-51. [Medline]

13. Bajwa SS, Bajwa SK, Kaur J, Sharma V, Singh A, Singh A, et al. Palonosetron: a novel approach to control post-operative nausea and vomiting in day care surgery. Saudi J Anaesth 2011;5(1):19-24. [Medline] [Free PMC Article] [SJA]

REFERENCES

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 59

oRIGINAL ARTIcLe

Diurnal variation of extremely low frequency electromagnetic field in an empty operating roomJae Wook Jung, MD1, Yong Han Kim, MD1, Gwang Cheol Go, MD1, Jae Hong Park, MD1, Sang Yoon Jeon, MD1 , Sang Eun Lee, MD1, Sira Bang, MD, Ph.D1, Ki Hwa Lee, MD1, Ki Hoon Kim, MD2

1Department of Anesthesiology and Pain Medicine; 2Department of Surgery Haeundae Paik Hospital, Inje University, Busan (South Korea)

Correspondence: Yong Han Kim, M.D., Department of Anesthesiology and Pain Medicine, Haeundae Paik Hospital, Inje University, Busan (South Korea); Tel: +82-51-797-0427; Fax: +82-51-797-0499; E-mail: adonis94@naver.com

ABSTRACTObjective: Extremely low frequency electromagnetic field (ELF-EMF) is harmful to human body and causes various diseases like cancer. ELF-EMF is mainly produced by surgical or anesthetic equipment in operating room. However, it can be made by surrounding electricity without electric device. We measured it in an empty operating room of our hospital over two days and nights.

Methodology: The intensity of ELF-EMF was measured as two-second interval for two days in an empty operat-ing room. One day was divided to three groups; night, morning, and afternoon. Each group continued for three hours due to capacity of ELF-EMF instrument. All of electrical devices were off including lamp, computer and air conditioner. Groups were compared using one-way ANOVA. P<0.05 was considered significant.

Results: Mean value of ELF-EMF during 1st and 2nd night was 1.9459 and 1.9486 respectively. It was lower than data of morning and afternoon (P<0.001). All values (100%) were above 2 mG (micro-Gauss) in daytime. In night time, most of ELF-EMF (99.9%) was below 2 mG.

Conclusion: The intensity of ELF-EMF is higher in an empty daytime operating room than at night time.

Keywords: Extremely low frequency electromagnetic field; Operating room; Diurnal variation; Electricity

Citation: Jung JW, Kim YH, Go GC, Park JH, Jeon SY, Lee SE, Bang S, Lee KH, Kim KH. Diurnal variation of extremely low frequency electromagnetic field in empty operating room. Anaesth Pain & Intensive Care 2013; 17(1):59-62

This article was presented as a poster in 6th International Baltic Congress of Anesthesiology and Intensive Care, 18th - 20th October 2012.

INTRODUCTIONThe invention of electricity brought revolutionary change and convenience in human society. However, many electronic devices are potentially harmful in as-pect of electromagnetic wave. The hazard of electro-magnetic field was first reported by Wertheimer and Leeper that children near electrical power lines have high prevalence of leukemia compared to control chil-dren in Colorado, 1976-1977.1 The biologic effect of extremely low frequency elec-tromagnetic field (ELF-EMF) to human body is not completely understood. In vitro study, powerful ELF-EMF can cause seizure, infertility, and DNA damage.2-5 Furthermore, recent study represented ELF-EMF over 4 mG (micro-Gauss) has a risk of brain tumor and leu-

kemia in pediatric population.6 ELF-EMF has received a lot of attention after first report of hazard in 1979.1 Along with the rise of electrical products in modern society, it draws a lot of focus dangerous or not. Lap-top computers is widely used in the public, but passed unobserved in impairment of health. Women can be influenced by Laptop computers, especially womb of pregnant.12 Female reproductive system would be af-fected by ELF-EMF that reduce the number of flushed blastocysts and augment the height of fallopian tube epithelium.2 In swine model, ELF-EMF intensity of 1mT corrupted sperm ability and interrupted fertiliza-tion.3 In addition, ELF-EMF exposure deforms synap-tic activity and steps up possibility of seizure activity in experimental condition to the rat.4 Catecholamine like adrenalin and dopamine was released by ELF-EMF on

60 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

ELF-EMF in empty operating room

cultured chromaffin cells.7 DNA integrity can be also affected by ELF-EMF.5

Children are easily influenced by environment and ELF-EMF is no exception. EMF has a possibility of carcinogen in leukemia and brain tumor.6 In recent study, Children living near power line are made a com-parison between 200m and 600m distance.8 The group of 200m power line represented high risk of acute lym-phocytic leukemia in Brazil. Occupational exposure of EMF decreases the level of cortisol in the serum among dentist group.9 The heart of rat was not influenced by short-term exposure of 1μT EMF.10

As advances in medical science and facilities, electric products and consumption are increasing rapidly in op-erating room. Medical staffs including anesthesiologist, surgeon, and nurse have high potential exposure to ELF-EMF in operating room for long period. A num-ber of equipment makes electromagnetic field that is formed by sum of individual electric product. Further-more, ELF-EMF may be built by invisible electric wir-ing system and other unidentified electric instrument. We hypothesized that ELF-EMF value is different as daytime and night time in empty operating room. TCO guideline by Swedish Confederation of Profes-sional Employees recommends under 2mG in the dis-tance of 30cm from electronic monitor.11

METHODOLOGYThis test was designed as prospective experimental study and conducted in an empty operating room of our university hospital. All the electrical equipment including computer, astral lamp, monitors, surgical and anesthetic devices had been put off in the operat-ing room. The intensity of ELF-EMF was measured as two-second interval for two days by ELF-EMF meter (TM-192D, Tenmars, Taiwan) (Figure 1).

Sample size was calculated by MedCalc version 11.6 as following conditions: type I error-alpha 0.05, type II error-beta 0.20, difference 0.01, standard deviation 1 – 0.1, standard deviation 2 – 0.1. Minimal required sample size was computed to be 1570. A day was divided into three groups; night (midnight to 3 AM), morning (8:30 AM to 11:30 AM), and after-noon (1:30 PM to 4:30 PM). Each group continued for three hours due to limits of capacity of ELF-EMF in-strument. The data were measured 5,400 times per each group. ELF-EMF meter was placed between operating table and anesthetic machine at about a height of one meter. Each group was compared by one-way ANO-VA using SAS 9.2 (SAS Institute, Cary, NC). Post-hoc test was conducted with Tukey procedure. Total night time data of two days was compared with total non-night time data of two days (day and afternoon) by Wilcoxon’s rank sum test.

RESULTSThe total average of ELF-EMF was 2.0718 ± 0.09059 (mean ± SD) (Table 1).

Table 1: The descriptive of ELF-EMF in empty operating room

Number of count

Mean (mG)

Standard deviation Minimum Maximum

1st night 5400 1.9459 0.01477 1.86 2.20

1st morning 5400 2.1115 0.02044 2.05 2.35

1st afternoon 5400 2.1251 0.01435 2.06 2.21

2nd night 5400 1.9486 0.01341 1.91 1.98

2nd morning 5400 2.1404 0.01381 2.09 2.20

2nd afternoon 5400 2.1593 0.01471 2.11 2.21

Total 32400 2.0718 0.09059 1.86 2.35

The mean value of ELF-EMF during 1st and 2nd night was 1.9459 and 1.9486 respectively (Figure 2). Average ELF-EMF of total night time was 1.9472 (Figure 3). 1st and 2nd night readings were significantly different than that of 1st and 2nd mornings and afternoons (Figure 3) (p< 0.001).

Table 2: The count of ELF-EMF over 2mG

ELF-EMF <2mG ELF-EMF >2mG Total

1st night 5395 5 54001st morning 0 5400 54001st afternoon 0 5400 54002nd night 5400 0 54002nd morning 0 5400 54002nd afternoon 0 5400 5400

Figure 1: ELF-EMF meter (TM-192D, Ten-mars, Taiwan)

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 61

original article

Time 1: 1st day from midnight to 3AM (5,400 data)Time 2: 1st day from 8:30AM to 11:30AM (5,400 data)Time 3: 1st day from 1:30PM to 4:30PM (5,400 data)Time 4: 2nd day from midnight to 3AM (5,400 data)Time 5: 2nd day from 8:30AM to 11:30AM (5,400 data)Time 6: 2nd day from 1:30PM to 4:30PM (5,400 data)

Figure 2: Mean ± SD values of ELF-EMF in mG for two days

Time 1 : 1st and 2nd day from midnight to 3AM (10,800 data)Time 2 : 1st and 2nd day from 8:30AM to 11:30AM and 1:30PM to 4:30PM (21,600 data)

DISCUSSIONIntensity of ELF-EMF was investigated during surgery at the position of anesthesiologist in another study,13 showing a mean of 5.83 mG and ratio over 2 mG was 70.98% in average of 18 operating rooms. Our study showed lower value because of empty operating room with no surgery. All the data of daytime was over 2 mG in our study, but nearly all was below 2 mG in

Figure 3: Mean value of ELF-EMF for night time and daytime period

night time (Table 2). Accurate determination of ELF-EMF is not easy. A lot of external factors can affect exact value, which may be a possible limitation in this study. The difference of ELF-EMF between 1st and 2nd daytime was consid-ered due to the number of operation cases. There were 39 operation cases on the 1st day and 75 cases on 2nd day in other functional operating rooms. Less number of cases on the first day meant that less electricity was used and less environmental ELF-EMF was formed to be recorded by our ELF-EMF meter. This is verified by the smaller minimum value of ELF-EMF during the daytime of the first day. It seems that even empty op-erating rooms can be under potential hazard in the face of whole electric mass. Protection equipment or EMF cut-off is necessary to reduce the risk. Expert electrical engineers should be employed to monitor its level and take appropriate measures to contain high levels for the safety of the staff and the patients, as ELF-EMF from electrical devices has been proven for possible harmful effects to the living animals, especially on the rapidly proliferating cells of the reproductive system,2,3 with possible repercussions to humans as well.1,4-6,8 More studies on this subject are required at different centres, taking into account the type and number of electromedical equipment used in the operating rooms, the usage of operating rooms and the type of electric source and cables used there. Microbiological studies are required in the healthcare workers, especially those who are exposed more to this hazard e.g. operating rooms, radiology and intensive care workers.

CONCLUSIONThe intensity of ELF-EMF is higher in an empty op-erating room at daytime than at night time. Medical personnel and patients can be exposed to high levels of ELF-EMF at daytime, hence it should be routinely monitored with or without electrical equipment in op-erating rooms. Conflict of interest: None declared.Support: This work was supported by an educational grant from Inje University, 2011.Acknowledgements: This work was supported by Grant from Inje University, 2011.

62 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

ELF-EMF in empty operating room

1. Wertheimer N, Leeper E. Electrical wiring con-figurations and childhood cancer. Am J Epide-miol 1979;109(3):273-84. [Medline]

2. Rajei F, Rorhani N, Sabbagh-Ziarari F, Ma-shayekhi F. Effect of extremely low-frequency electromagnetic field on fertility and heights of epithelial cells in pre-implantaion stage en-dometrium and fallopian tube in mice. Zhong Xi Yi Jie He Xue Bao. 2010 Jan; 8(1):56-60. [Medline] [Free Full Article]

3. Bernabo N, Tettamanti E, Russo A, Martelli M, Turriani M, Mattoli M, et al. Extremely low fre-quency electromagnetic field exposure affects fertilization outcome in swine animal model. Theriogenology 2010;73:1293-1305. [Medline] doi: 10.1016/j.theriogenology.2009.12.010.

4. Varró P, Szemerszky R, Bárdos G, Világi I. Changes in synaptic efficacy and seizure sus-ceptibility in rat brain slices following extremely low-frequency electromagnetic field exposure. Bioelectromagnetics 2009 Dec;30(8):631-40. [Medline] doi: 10.1002/bem.20517.

5. Focke F, Schuermann D, Kuster N, Schar P. DNA fragmentation in human fibroblasts un-der extremely low frequency electromagnetic

field exposure. Mutation Research 2010 Jan 5;683(1-2):74-83. [Medline]

6. Schuz J. Exposure to extremely low-frequency magnetic fields and the risk of childhood cancer: update of the epidemio-logical evidence. Prog Biophys Mol Bio 2011 Dec;107(3):339-42. [Medline] doi: 10.1016/j.pbiomolbio.2011.09.008.

7. Verdug-Diaz L, Olivares-Banuelos T, Navarro L, Drucker-Colin R. Effects of extremely low frequency electromagnetic field stimulation on cultured Chromaffin cells. Ann NY Acad Sci 2002 Oct;971:266-8. [Medline]

8. Wunsh-Filho V, Pelissari DM, Barbieri FE, Sant’Anna L, de Oliveira CT, de Mata JF, et al. Exposure to magnetic fields and childhood acute lymphocytic leukemia in São Paulo, Bra-zil. Cancer Epidem 2011;35:534-9. [Medline] doi: 10.1016/j.canep.2011.05.008.

9. Mortazavi SM, Vazife-Doost S, Yaghooti M, Mehdizadeh S, Rajaie-Far A. Occupational exposure of dentists to electromagnetic fields produced by magnetostrictive cavitrons alters the serum cortisol level. J Nat Sci Biol Med 2012 Jan;3(1):60-4. [Medline] [Free PMC Ar-

ticle] doi: 10.4103/0976-9668.95958.10. Elmas O, Comlekci S, Koylu H. Effects of

short-term exposure to powerline-frequency electromagnetic field on the electrical ac-tivity of the heart. Arch Environ Occup Health 2012;67(2):65-71. [Medline] doi: 10.1080/19338244.2011.578680.

11. Habash R. Guidelines and measurement for electric and magnetic fields. In: Bioeffects and Therapeutic Applications of Electromagnetic Energy. 1st edition. CRC Press, USA:2008; pp59-82.

12. Bellieni CV, Pinto I, Bogi A, Zoppetti N, An-dreuccetti D, Buonocore G. Exposure to electromagnetic fields from laptop use of laptop computers. Arch Environ Oc-cup Health 2012;67(1):31-6. [Medline] doi: 10.1080/19338244.2011.564232.

13. Roh JH, Kim DW, Lee SJ, Kim JY, Na SW, Choi SH et al. Intensity of extremely low-frequency electromagnetic fields produced in operating rooms during surgery at the standing position of anesthesiologists. Anesthesiology 2009 Aug;111(2):275-8. [Medline] [Free Full Article] doi: 10.1097/ALN.0b013e3181a9188b.

REFERENCES

FRee JoB ADVeRTIsINGAPICARE offers free placement of job announcements for anesthesiologists, intensivists, pain management specialists and resuscitation specialists, in our print edition as well as online on our website www.apicareonline.com. The offer is extended as a service to our esteemed readers. The announcement may be edited for the sake of clarity and brevity. The journal reserves the right to accept or reject any announcement without assigning any reason

FRee PosTeRsAPICARE intends to publish and distribute free of cost, posters based on resuscitation algorithms and airway management algorithms, based upon recommendations by resuscitation societies and Difficult Airway Society (DAS) of UK. We have invited distributors and manufacturers of resuscitation equipment as well as drugs to sponsor free posters. Posters will be published in 4 colours, in 22 inches x 17 inches for framing or mounting and displaying prominently in the operating rooms as well as intensive care units and emergency rooms. We wish to express our sincere gratitude to the RCUK, AHA, ARS and DAS for their kind permission to use their material for this purpose.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 63

sHoRT coMMUNIcATIoN

The prevalence of obstructive sleep apnea characteristics in patients with Barrett’s esophagusMedhat Hannallah, MD, FFARCS*, Yonette Exeter, CRNP**, Maggie Gillespie, MD***, Jason Hoefling, MD****

*Professor, **Nurse Practitioner, ***Resident, ****Assistant ProfessorDepartment of Anesthesia, Georgetown University Hospital, Washington DC, USA.

Correspondence: Medhat Hannallah, MD, FFARCS, Department of Anesthesia, Georgetown University Hospital, 3800 Reservoir Road, SW, Washington DC, 20007, USA. Phone: 202-444-6680. Email: hannallm@gunet.georgetown.edu

ABSTRACTAn increasing number of patients with Barrett’s espophagus present for diagnostic and/or therapeutic upper GI endoscopy. It has been our impression that a large number of these patients have history and characteristics strongly suggestive of obstructive sleep apnea (OSA), and are, therefore, more challenging to sedate during the upper GI endoscopic procedures. This study was conducted to prospectively quantify the prevalence of OSA characteristics in patients with Barrett’s esophagus. Consented patients with Barrett’s esophagus were prospectively screened for obstructive sleep apnea (OSA) risk using the modified neck circumference questionnaire. The study demonstrated a statistically significant association between Barrett’s esophagus and high OSA risk when compared to the general GI endoscopy population.

Key words: Barrett’s esophagus; Obstructive sleep apnea.

Citation: Hannallah M, Exeter Y, Gillespie M, Hoefling J. The prevalence of obstructive sleep apnea characteristics in patients with Barrett’s esophagus. Anaesth Pain & Intensive Care 2013;17(1):63-64

INTRODUCTIONPatients with obstructive sleep apnea (OSA) are at increased risk of sedation-related morbidity and mortality. The risk increases in proportion to the severity of the OSA because of the potential difficulty in maintaining a patent airway.1 An increasing number of patients with Barrett’s esophagus present for diagnostic and/or therapeutic upper GI endoscopy such as radiofrequency ablation (Barrx procedure).2 It has been our impression that a large number of these patients have history and characteristics strongly suggestive of OSA, such as snoring, large neck circumference, hypertension, and choking during sleep. They are, therefore, more challenging to sedate during the upper GI endoscopic procedures. This is particularly the case during the Barrx procedure which is longer than a diagnostic upper GI endoscopy and requires multiple insertions of the endoscope. Since the exact incidence of OSA in this patient population has not been determined, we coducted this study to prospectively quantify the prevalence of OSA characteristics in patients with Barrett’s esophagus.

METHODOLOGYWith IRB approval and written informed consent, outpatients presenting for GI endoscopy over a consecutive 4-week period, who had a confirmed diagnosis of Barrett’s esophagus, were screened for OSA risk, using the modified neck circumference questionnaire routinely used for preoperative OSA screening at our hospital.3 The questionnaire asks the patient about history of snoring, hypertension, and nighttime choking. The patient’s neck circumference is measured in cm and the measurement is then modified according to the response to the questionnaire, adding 4 points for a positive history of hypertension and 3 points

each to a positive history of snoring and nighttime choking. Patients with modified neck circumference score greater than 48 are considered at high risk for having severe OSA.(Box 1)

Box 1: Modified Neck Circumference Questionnaire.3

1) Neck circumference in cm. 2) History of snoring: add 3 points. 3) Hypertension: add 4 points. 4) Nighttime chocking: add 3 points.Total items 1-4. A score > 48 indicates a high probability of OSA.

64 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

obstructive sleep apnea with Barrett’s esophagus

For comparison, all outpatients presenting for GI endoscopy on two consecutive days were similarly screened for OSA risk. Whether to use the data for a pilot or a defenitive study was to be determined following statistical analysis of the data and determination of the significance of the difference between the two groups.

RESULTSTwenty five patients with confirmed diagnosis of Barrett’s esophagus were screened. Twelve out of the 25 patients (48%) had modified neck circumference score greater than 48 indicating high probability of OSA. Forty six patients were screened in the control group. Seven out of the 46 patients (15%) had a score greater than 48. The data, compared using Fisher’s exact test, showed a statistically significant association between Barrett’s esophagus and high OSA risk when compared to the general GI endoscopy population (P = 0.0047). Furthermore, the data demonstrated that patients with Barrett’s esophagus were 5.14 times more likely to possess OSA characteristics (95% confidence interval: 1.67-15.82) than patients without the condition. The strength of the statistical significance between the two groups justify using the results as defenitive data.

DISCUSSIONThis study confirmed the high prevalence of OSA characteristics in patients with confirmed diagnosis of Barrett’s esophagus compared to the general GI endoscopy population. Barrett’s esophagus is defined as intestinal metaplasia of the esophageal epithelium which affects patients with gastroesophageal reflux disease (GERD).2 Obesity is a key risk factor to both OSA and GERD.4 Kahrilas raised the question of whether OSA and GERD commonly coexisted because of shared risk factors or because a causal relationship existed between them.5 He reviewed different studies on the topic and concluded that the most compelling argument is that people with OSA are more likely to be obese and more likely to have hiatus hernia, and that it was the hernia that predisposed obese people to nocturnal reflux with

prolonged esophageal acid exposure. This explains why patients with Barrett’s esophagus have a higher incidence of OSA than the general population.The high prevalance of OSA characteristics in patients with Barrett’s esophagus warrants careful screening of these patients for OSA risk and consideration of different airway protection options when sedating them for upper GI endoscopy particularly during long theraputic procedures. While propofol, when available, usually provides effective and safe anesthesia for upper GI endoscopy in most patient, consideration of alternative anesthesia techniques such as light sedation, topical airway anesthesia, dexmedetomidine supplementation and/or elective endotracheal intubation may be needed in patients with Barrett’s esophagus who have the difficult airway characteristics associated with OSA.Limitations: Our study has the limitation that although it indicates an interesting correlation between Barrett’s esophagus and GERD, there may not be a true association rather one that occurs because both conditions (Barrett’s and OSA) are associated with other factors including obesity. In order to rule this out, a multivariate analysis needs to be performed comparing the demographic and clinical findings between the two groups. For example, is there a weight difference between the two populations studied (Barrett’s and non-Barrett’s)? We feel that a larger sample size with complex statistical analysis may confirm the findings or otherwise.

CONCLUSIONThis study demonstrated a statistically significant association between Barrett’s esophagus and high OSA risk when compared to the general GI endoscopy population. Awareness of this finding is important when screening patients with Barrett’s esophagus and when considering different airway management options during their sedation for upper GI endoscopy.Conflicts of Interest: The authors have no personal or financial conflicts of interest.

1. Chung SA, Yuan H, Chung F. Systemic Review of Obstructive Sleep Apnea and Its Implications for Anesthesiologists. Anesth Analg 2008;107(5):1543-63. [Medline] [Free Full Article] doi: 10.1213/ane.0b013e318187c83a.

2. Shaheen NJ, Sharma P, Overholt B, Wolfsen HC, Sampliner RE, Wang KK,

et al. Radiofrequency Ablation in Barrett’s Esophagus with Dysplasia. N Engl J Med 2009;360(22):2277-88. [Medline] [Free Full Article] doi: 10.1056/NEJMoa0808145.

3. Flemons WW. Obstructive sleep apnea. N Engl J Med 2002;347(7):498-504. [Medline] [Free Full Article]

4. Talwar V, de Caestecker JS. What is the relationship between gastro-oesophageal reflux and obstructive sleep apnoea? Dig Liver Dis. 2006;38(2):82-4. [Medline]

5. Kahrilas PJ. Obstructive sleep apnea and reflux disease. Chest 2010;137(4):747-8. [Medline] [Free Full Article] doi: 10.1378/chest.09-2496.

REFERENCES

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 65

ReVIeW ARTIcLe

Prehospital trauma care services in developing countriesLakesh Kumar Anand, MD, FCCP, FIMSA, FCCS, MAMS*, Manpreet Singh, MD, FCCP, FIMSA, FACEE, FCCS**, Dheeraj Kapoor, MD, FCCP, FACEE, FCCS***

*Associate Professor; **Assistant ProfessorDepartment of Anaesthesia & Intensive Care, Government Medical College & Hospital, Sector 32, Chandigarh (India)

Correspondence: Dr Manpreet Singh, Department of Anaesthesia & Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh (India); E-mail: manpreetdawar@gmail.com

ABSTRACT Trauma is a leading cause of death and disability especially amongst young people. Prehospital trauma care service remains a dynamic field of medicine for care of trauma patients. The goal of prehospital emergency care system should be to match the needs of the patients to the available resources so that optimal, prompt and cost-effective care can be offered. For bridging the wide gap between the actual and expected level of care, the urgent need must be appreciated by the community, administration, medical professionals and very positive steps should be taken to meet the future challenges. The authors included a “snapshot” of current articles applicable to prehospital trauma care in developing countries. The current review aims to explore the concept of “golden hour” and objectives, controversies and existing status of prehospital trauma care service using the recent evidence based literature in developing countries. Keywords: Prehospital trauma care service; Trauma care; Golden hour; Prehospital traumaCitation: Anand LK, Singh M, Kapoor D. Prehospital trauma care services in developing countries. Anaesth Pain & Intensive Care 2013;17(1):65-70

INTRODUCTION Management of trauma is a neglected field in developing nations.1 The World Health Organization (WHO) estimates that 5.8 million deaths annually are attributable to injuries, 90% of which occur in developing countries 2 with mortality rates expected to increase as these nations further develop, urbanize, and industrialize.3,4 In addition, an overwhelming proportion of these deaths occur before patients even reach the hospital.5 Two third (60.7%) of the accident victims belonged to the age range of 15 to 44 years.6 This is the economically productive age-group and major financial support for their families. Lack of medical attention attributed to 30 per cent of deaths at site and 80 per cent of the remaining patients died within an hour of injury (golden hour).7 Most of these deaths are due to airway management failure, respiratory failure or continuing haemorrhage that are preventable causes with appropriate prehospital and subsequent hospital emergency care.8 As a result, governments in developing countries have been attempting to establish and strengthen prehospital emergency medical systems that can provide patients with prehospital basic life support (BLS) and transportation to higher care.4,9

Unfortunately, prehospital trauma care is not available to most of the world’s population and India is no exception.

THE CONCEPT OF “GOLDEN HOUR” One of the most well known principles in medicine is ‘‘golden hour’’ of trauma , which specifies that patients outcome are improved when patient is transported to a designated trauma centre within an hour of injury. Nearly all emergency medical services (EMS) providers can remember their first exposure to the concept of the “golden hour” with the idea that trauma patients have significantly better survival rates if they reach surgery within 60 minutes of their injury. The “golden hour” summarized by the 3R rule of Dr Donald Trunkey, an academic trauma surgeon, “Getting the right patient to the right place at the right time.”10 But the concept of golden hour is still questionable in most of countries. In a 2001 literature review, Lerner EB et al,11 determined the origin of the term “golden hour”. They cited a series of studies discussing the golden hour, but noticed that those studies often referenced one another and were not accompanied by supporting data or references to other studies. Most frequently the phrase is attributed

66 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

prehospital trauma care services in developing countries

to Cowley, who used it in 1973 with reference to helicopter transport of injured patients in Maryland.12.A retrospective cohort of adult patients with severe head injuries was conducted to determine the effect of patient arrival within the golden hour on patient outcomes. Study outcomes were in-hospital mortality and survival to hospital discharge without requiring transfer for ongoing rehabilitation or nursing home care. Authors concluded that, a survival benefit exists in patients arriving earlier to hospital after severe head injury but the benefit may extend beyond the golden hour. There was evidence of improved functional outcomes in patients arriving within 60 min of injury time.13 Further, according to National Emergency Medical Services Education Standards; “golden period” is still listed as a guideline for teaching trauma care.14 Although it would seem intuitive that treating patients more rapidly results in reduced mortality and secondary injury but the evidence for the “golden hour” in general and timing of reaching hospital on patient outcomes is limited.Recently, prehospital management and outcome of polytrauma patients was compared between two countries (Scotland and Germany) with differing approaches to prehospital management. The mean time from an injury to arrival to the emergency department (73 vs. 247 minutes) was longer for the Scottish patients. Despite variation in prehospital transfer times and interventions, no significant difference was demonstrated in revised trauma score upon arrival, or for the unadjusted mortality rates.15 Prospective data from 146 EMS transport agencies over a 16 month period from 2005 to 2007 were analyzed for 806 trauma deaths in a pool of 3656 patients (22% mortality). After multivariate, subgroup, and instrumental analyses, no significant association was found between time and mortality for any EMS interval (activation, response, on-scene, transport, and total time) among injured patients with physiologic abnormalities.16 Similarly, data by Lichtveld et al17 confirms what was noted in a Dutch single-centre prospective study in 2007. Among other conclusions, this study also noted “the time interval between the accident and arrival at the hospital does not appear to affect the risk of death.” Further, the pressure to arrive at the hospital within the “golden hour” may increase the number of emergent transports, which have been demonstrated to increase the risk for collisions resulting in injury and fatality.

OBJECTIVES OF PREHOSPITAL TRAUMA CARE The prehospital trauma care process consists of six key

steps: detection, reporting, response, on-scene care, care in transit and transfer to definitive care18 inspired from the EMS-symbol or so-called ‘Star of Life’ symbol created by the US National Highway Traffic Safety Administration which presents six EMS functions.19 Objectives of prehospital trauma care involve prompt communication and activation of the system, proper actions at the scene of the crash by first responders, and the prompt response of the system or simply offer fastest possible basic life support includes, airway, breathing, control of bleeding, and transportation of the right patient to the right place at right time.3,20 This includes all the appropriate personnel safety precaution, assessment, and treatment of the injured people at the scene, and transport to trauma care facilities while delivering the necessary medical care before arrival at the hospital. Widespread first-aid training is the most important aspect of successful prehospital care. Level of care, offered at the site, varies according to the facilities available in a given situation.8

First responder care: Motivated volunteers from community, fire-fighters, police, and laypersons trained to provide initial first aid can only offer fastest possible care. For best possible prehospital trauma care expected actions from trained bystanders are: getting involved, call for help, assessing the safety of the scene, assessing the victim, capable of appreciating seriousness of emergency and extend initial care, all will fail if bystanders are not getting involved.

Basic prehospital trauma care: This care is provided by the community members exposed to formal training in prhospital BLS, scene management, rescue, stabilisation and transportation of injured persons to the definite facility safely without causing further harm. Appropriate training had been advocated for skill enhancement to ensure control of external haemorrhage by direct or indirect pressure, protection of spine, provision of artificial respiration, circulatory support, oxygen therapy and extrication.

Advanced prehospital trauma care: Advanced life support at prehospital level is resource intensive and is expected to be provided by highly skilled medical professionals or paramedical staff. The ATLS21 care recommendation includes intravenous fluid therapy, endotracheal intubation, and highly invasive interventions such as needle decompression or cricothyroidotomy. Despite the enormous cost involved, this kind of care has not been proved to be beneficial except for small subset of very critically ill patients. Cost benefit analysis, therefore, is necessary before planning to introduce such facility.8

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 67

review article

CONTROVERSIAL INTERVENTIONS “Stay and play” versus the “scoop and run” Main potential benefit of “scoop and run” is minimise delay to definite care, other potential benefit depend on mechanism of injury, specific prehospital interventions and transport distance. However, the question of attempted “Stay and play” versus “scoop and run” approach in the management of trauma has no clear-cut answer.22,23 In real life situation a balance is necessary based on the transport distance, pre-hospital resources, and mechanisms of injury (blunt vs. penetrating trauma). Decision should be taken by the healthcare provider accordingly at the site of incidence. Airway managementAirway management had been advocated in patients with traumatic brain injury, cervical spine, or thoracic trauma before evacuation unless the same can be performed easily en route.24 Despite the claimed advantages, prehospital endotracheal intubation (ETI) and rapid-sequence induction performed by less experienced paramedical staff leads to higher mortality and poorer neurologic outcomes.25 Studies on prehospital ETI showing survival benefit in severe head injury,26,27 harm in haemorrhagic state28,29 and no difference30,31 over bag-valve-mask ventilation. Use of ETI in the prehospital care environment remains controversial.32 Well-designed randomized trials are necessary to assess the efficacy and risks associated with prehospital ETI. Alternatives to endotracheal intubation including, Laryngeal mask Airway, Combitube, Easy tube and Laryngeal tube are easier to insert when compared to endotracheal intubation by providers after minimal training.33,34

Fluid replacement Prehospital fluid resuscitation for major trauma is controversial.32 The harm associated with prehospital intravenous (IV) fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged. Current trends are for limited crystalloid resuscitation and early use of blood and blood products before haemorrhage control in prehospital setting for both blunt and penetrating injury. Maximum attention should be on preventing the lethal triad of trauma: hypothermia, acidosis, and coagulopathy.25,32,35

Spine Immobilization in Penetrating TraumaSpine immobilization, like IV fluid administration, ETI and field stabilization has the potential to delay the transport of trauma patients. It is often part of the current prehospital treatment for patients with penetrating injuries to the head, neck, or torso, although there are no definitive studies that demonstrate its

benefit.36,37 Some authorities have instituted selective immobilization protocols based on injury mechanism. However, many prehospital protocols advise for spine immobilization whenever there is potential for spinal cord injury.37,38 In contrast, prehospital trauma life support (PHTLS) course and textbook state that spine immobilization is not indicated in patients with penetrating trauma to the head, neck, or torso without neurologic deficit or complaint.39 Also supported by retrospective analysis of penetrating trauma patients in the National Trauma Data Bank, in which patients were compared with and without prehospital spine immobilization. Authors concluded that, prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma.40

PREHOSPITAL TRAUMA STATUS IN INDIACentralised Accident & Trauma Services (CATS), an autonomous body formed in 1991 by the Delhi government was probably the first comprehensive initiative to improve pre-hospital trauma service. Emergency Management and Research Institute (EMRI), Hyderabad, Ambulance Access for All (AAA), Foundation and Emergency and Accident Relief Centre (EARC) are other service providers in Andhra Pradesh, Maharashtra and Tamil Nadu respectively. For faster response Ambulance Motorbike and Rescue Service (AMARS) was initiated in March 2003 by Christian Medical College, Ludhiana to offer support in Punjab, Himachal Pradesh, Jammu and Delhi.20 National Rural Health Mission (NRHM) access started through 108. Recently, Active Network Group of Emergency Life Savers (ANGELS) access through 102 has been started. Trained paramedical staffs had been involved by all the above agencies for offering pre-hospital emergency care.Despite increased awareness of the global impact of injury and existing system, it has been highlighted41 that the field of trauma care and emergency medicine has not progressed uniformly in the country and it is still at a primitive stage. Assessment of prehospital care is essential in order to guide future efforts to strengthen the overall systems. Nielsen et al42 attempted to understand the methods of transport to the hospital, training and certification of EMS providers, organization and funding of EMS systems, public access to prehospital care, and barriers to further prehospital care development in thirteen wide ranges of low- and middle income countries (LMICs). A standardized 32-question was derived from needs assessment forms originally created by WHO, based on the prehospital

68 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

prehospital trauma care services in developing countries

trauma care systems publication8 and which had been pilot tested and refined in several countries previously. Information was gathered via a combination of personal visits, phone interviews, e-mail, and letters. Data were gathered during 2009-2010. Study included EMS leaders and other key informants in thirteen LMICs. Result shows that, prehospital care capabilities varied significantly, but in general were less developed in low-income countries and in rural areas, where utilization of formal EMS was often very low. Commercial drivers, volunteers, and other bystanders provided a large proportion of prehospital transport and occasionally also provided first aid in many locations. The most frequently cited barriers to further development of prehospital care were inadequate funding (36%). The next most commonly cited barriers were lack of leadership within the system (18%) and lack of legislation setting standards (18%). Authors concluded that, expansion of prehospital care to currently underserved or unserved areas, especially in rural areas, could make use of the already-existing networks of first responders, such as commercial drivers and laypersons. Also, added that efforts to increase their effectiveness, such as more widespread training accordingly, and better encompassing their efforts within formal EMS, are justified. There is a need for increased and more regular funding, integration and coordination among existing services, and improved organization and leadership, as could be accomplished by making EMS administration and leadership a more desirable career path.Later on isolated study appeared form different countries to provide some useful ideas on prehospital solution. Waseem et al43 presented a model of prehospital emergency services which fulfilled the guidelines of WHO, called Rescue 1122. Authors has described the process of establishment of the service, the organisational structure, the scope of services and the role it was playing in the healthcare services of the designated region. The system was well supported by government funding. Authors agreed that, Rescue 1122 has managed to set up a low cost, effective system of prehospital care which can be replicated in other developing countries with little or no modification. However, prospective and retrospective clinical trials are needed to verify the efficacy of the system and its role in the healthcare sector. Study by Murad et al44 evaluated a prehospital trauma system model, to which extent a low-cost trauma system reduces trauma deaths where prehospital transit times are long, and to identify specific life support interventions that contributed to survival. Ten year study period from 1997 to 2006; included 2,788 patients

injured by land mines, war, and traffic accidents were managed by a chain-of-survival trauma system where non-graduate paramedics were the key care providers. The results of study show that, 37% of the study patients had serious injuries with Injury Severity Score ≥ 9. The mean prehospital transport time was 2.5 hours. Trauma mortality was reduced from 17% to 4%, survival especially improving in major trauma victims. In most patients with airway problems, chest injured, and external haemorrhage, simple life support measures were sufficient to improve physiological severity indicators. It was concluded that, in case of long prehospital transit times simple life support measures by paramedics and lay first responders reduce trauma mortality in major injuries. Assigning life-saving skills to paramedics and lay people is a key factor for efficient prehospital trauma systems in low-resource communities. Henry et al45 conducted a systematic review and meta-analysis to assess the effectiveness of prehospital trauma systems in developing countries. Multiple database and bibliography searches were conducted to identify articles assessing the effectiveness of prehospital trauma systems in developing countries. The primary outcome was mortality. Secondary outcomes were physiologic severity score; Injury Severity Score, and prehospital time, appropriate statistical analysis was done. Out of fourteen studies, eight representing seven countries (n = 5,607) were included in the meta-analysis. Their pooled estimated results show a 25% decreased risk of dying from trauma in areas that have prehospital trauma systems. In-field response time was reduced in both rural and urban settings. Authors concluded that, prehospital trauma systems in developing countries, particularly middle-income countries, reduce mortality.Recently, Sun et al46 conducted the study, by using a prehospital care system and implementation strategy that was more appropriate for a range of conditions in South Africa. This model utilizes a core emergency first aid responders (EFAR) system model that can be locally adapted, along with an implementation strategy that could be done in a graduated fashion within an area’s means. Motivated local community members were trained to become EFAR who can provide immediate, on -site care until a transporter can take the patient to the definite hospital. Management of the system was done through local community based organizations, which can adapt the model to their communities. Within a community, the system was implemented in a graduated manner based on available resources, and was designed to not rely on the whole system being implemented first to provide partial function. Authors

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 69

review article

concluded that, strategy was a versatile prehospital emergency care model with emergency need, and shows great promise in making prehospital emergency care more accessible in under-developed areas of South Africa. Interestingly, The University of Cape Town’s Division of Emergency Medicine and the Western Cape’s provincial METRO EMS intend to follow this model, along with sharing it with other South African provinces.As developing countries begin to urbanize and grow, so do their health care needs. The current system does not meet the needs of increased mortality from trauma. Various factors identified those hinder or facilitate an effective prehospital trauma care process: administration and organization, staff qualifications and competences, availability and distribution of resources and communication and transportation are inside the EMS and involvement of other organizations, laypeople and the general infrastructure are outside the EMS. The core factor is interaction and common understanding in the medical and non-medical sector.42,47

CONCLUSIONA prehospital trauma care service remains a dynamic field of medicine for care of trauma patients. Therefore, improvements in the field of trauma services are required to ensure “golden hour” compliance for all trauma victims as an achievable goal by coordinating activities between prehospital care and specialized hospital care services. One technical aspect of prehospital trauma care is to improve access and to establish a uniform emergency access telephone number. Due to great heterogeneity in the literature, firm conclusions cannot be drawn. However, present literature review provides useful information about the current status of prehospital trauma care in developing countries that will assist in strengthening and expansion of prehospital trauma care. A specific and unique model system should be developed to address the needs of the trauma patient. The goal should be to get ‘the right patient, to the right place, at the right time, to receive the right care’ following trauma.

1. Trauma in India-Fact files available at http://www.traumaindia.org/traumainindia.htm [Available Online]

2. World Health Organization. Injuries and violence: the facts. Geneva: World Health Organization, 2010. Available at: http://www.who.int/violence injury prevention/key facts/en/index.html. [Available Online]

3. Maertens F, Anstey C. Crime, violence, and development: trends, costs, and policy options in the Caribbean. United Nations office on drugs and crime Latin America and the Caribbean region of the World Bank. United Nations: UN Latin America and the Caribbean Regional Office; 2007. [Available Online]

4. Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ 2002;324:1139-41. [Medline] [Free Full Text]

5. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000; 90: 523-6. [Medline] [Free Full Text]

6. National Crime Records Bureau. Accidental deaths and suicides in india-2009. Report. Ministry of Home Affairs, Government of India, New Delhi; 2010; 6-7. Available from: http://www.ncrb.nic.in/CD-ADSI2009/ADSI2009-full-report.pdf. [Available Online]

7. ‘In an Emergency…’.The Hindu. June 13 2002; Available at: http://www.hindu.com/thehindu/ mp/2002/06/13/stories/2002061300180300.htm.

8. Sasser S, Varghese M, Kellermann A. et al. WHO Pre-hospital trauma care systems. World Health Organization Geneva

2005. Available at http://www.who.int/violence_injury_prevention/ publications/services/39162_oms_n w.pdf [Available Online]

9. Wisborg T, Murad MK, Edvardsen O, Husum H. Prehospital trauma system in a low-income country: system maturation and adaptation during 8 years. J Trauma 2008;64:1342-8. [Medline]

10. Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am 1983; 249:28-35. [Medline]

11. Lerner EB, Moscati RM. The golden hour: Scientific fact or medical “urban legend”? Acad Emerg Med 2001 Jul;8(7):758–60. [Medline]

12. Cowley RA, Hudson F, Scanlan E, et al. An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland. J Trauma 1973;13(12):1029-38. [Medline]

13. Dinh MM, Bein K, Roncal S, Byrne CM, Petchell J, Brennan J. Redefining the golden hour for severe head injury in an urban setting: The effect of prehospital arrival times on patient outcomes. Injury (2012), doi:10.1016/j.injury.2012.01.011 (in press) [Medline]

14. National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines. National Highway Traffic Safety Administration, http://www.

ems.gov/pdf/811077e.pdf. [Available Online]15. Tan XX, Clement ND, Frink M et al. Pre-

hospital trauma care: A comparison of two healthcare systems. Indian J Crit Care Med 2012;16:22-7. [Medline] [Free Full Text] [

16. Newgard CD, Schmicker RH, Hedges JR at al. Emergency medical service intervals and survival in trauma: assessment of the ‘golden hour’ in a North American prospective cohort. Ann of Emerg Med 2010;55(3):235-46. [Medline] [Free Full Text]

17. Lichtveld RA, Panhuizen IF, Smit RBJ et al. Predictors of death in trauma patients who are alive on arrival to hospital. European Journal of Trauma and Emergency Surgery. 2007;33:46-51. [Available Online] [Free Full Text]

18. Sinthavalai R, Memongkol N, Patthanaprechawong J, et al: A study of distinctive model for pre-hospital EMS in Thailand: Knowledge capture. World Academy of Science, Engineering and Technology 2009, 140-145. [Free Full Text]

19. National Highway Traffic Safety Administration: “Star of Life”: Emergency Medical Care Symbol-Background, Specifications, and Criteria. U.S. Department of Transportation, National Highway Traffic Safety Administration; 1995 Available at http://www.ems.gov/vgn-ext-templating/ems/sol/index.htm. [Online Access]

20. Goyal HC et al. Report of a 2 day National consultation on Pre Hospital Trauma Care in India on 26th and 27th October 2006 at NIHFW, Munirka, New Delhi. [Free Full Text]

21. Cotton BA, Jerome R, Collier BR, et al.

REFERENCES

70 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

prehospital trauma care services in developing countries

Guidelines for prehospital fluid resuscitation in the injured patient. J Trauma 2009;67:389-402. [Medline]

22. Haas B, Nathens AB. Pro/con debate: Is the scoop and run approach the best approach to trauma services organization? Critical Care 2008, 12:224. doi: 10.1186/cc6980. Epub 2008 Sep 10. [Medline] [Biomed Central Free full Text] [PMC Free Full Text]

23. Gold CR. Prehospital advanced life support vs “scoop and run” in trauma management. Ann Emerg Med 1987 Jul;16(7):797-801. [Medline]

24. Christensen EF, Deakin CD, Vilke GM, Lippert FK. Prehospital care and trauma systems. pp: 43-58 in TRAUMA Emergency Resuscitation Perioperative Anesthesia Surgical Management Volume 1 Editors: Wilson WC, Grande CM. Publishers: Informa Health care. USA, 2007.

25. Adult Advanced Life Support. Resuscitation council UK, 2010: page 58-80. [Free Full Text]

26. Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ et al .Prehospital rapid sequence intubation improves functional outcomes for patients with severe traumatic brain injury: a randomized controlled trail. Ann Surg 2010;252(6):959-65. [Medline]

27. Vandromme MJ, Melton SM, Griffin R, et al. Intubation patterns and outcomes in patients with computed tomography-verified traumatic brain injury. J Trauma 2011;71(6):1615-9. [Medline]

28. Shafi S, Gentilello L. Prehospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decresed survival in hypovolemic trauma patients: an analysis of the national trauma data bank. J Trauma 2005;59(5):1140-5; discussion 1145-7. [Medline]

29. Denver Metro Airway Study Group. A prospective multicenter evaluation of prehospital airway management in a large metropolitan region. Prehosp Emerg Care 2009;13(3):304-10. [Medline]

30. Helm M, Hossfeld B, Schafer S, Hiotz J, Lampl L. Factors influencing emergency intubation in the pre-hospital setting- a

multicentre study in german helicopter emergency medical service. Br J Anaesth 2006 Jan;96(1):67-71. [Medline] [Publisher Free Full Text]

31. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;283(6):783-90. [Medline] [Publisher Free Full Text]

32. Kerby JD, Cusick MV. Prehospital emergency trauma care and management. Surg Clin North Am 2012;92(4):823-41. [Medline]

33. Nolan JP, Deakin CD, Soar J, et al. European Resuscitation Council guidelines for resuscitation 2005. Section 4 Adult advanced life support. Resuscitation 2005;67:39-86. [Medline]

34. Chianti H, Soulleihet V, Massa H et al. The Easytube? for airway management in pre-hospital emergency medicine. Resuscitation 2010;81:1516-20. [Medline]

35. Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a national trauma data bank analysis. Ann Surg 2011;253(2):371-7. [Medline]

36. Connell RA, Graham CA, Munro PT. Is spinal immobilization necessary for all patients sustaining isolated penetrating trauma? Injury. 2003;34:912-4. [Medline]

37. Domelier RM, Fredericksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46:123-31. [Medline]

38. Burton JH, Dunn MG, Harmon NR, Hermanson TA, Bradshaw JR. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006;61:161-7. [Medline]

39. Salomone JP, Pons PT, McSwain NE, eds. Prehospital Trauma Life Support. 6th ed. St. Louis: Mosby; 2007: p235.

40. Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninge AN et al. Spine immobilization in penetrating trauma: More

harm than Good? J Trauma 2010;68:115-21. [Medline]

41. McIntosh B, Sheppy B, Rane S. An Indian tragedy, an Indian solution: perspective of managing service quality in emergency medical services in India. Journal of Global Health Care Systems 2012;2(1):1-8. [Publisher Abstract] [Publisher Free Full Text]

42. Nielsen K, Mock C, Joshipura M et al. Assessment of the status of prehospital care in 13 low-and middle-income countries. Prehosp Emerg Care 2012;16(3):381-9. [Medline]

43. Waseem H, Rizwan Naseer R, Razzak JA. Establishing a successful pre-hospital emergency service in a developing country: experience from Rescue 1122 service in Pakistan. Emerg Med J 2011;28:513-15. [Medline] [Free Full Text]

44. Murad MK, Larsen S, Husum H. Prehospital trauma care reduces mortality. Ten year results from a time-cohort and trauma audit study in Iraq. Sacnd J Trauma Resusc Emerg Med 2012 Feb 3; 20:13. doi: 10.1186/1757-7241-20-13. [Medline] [PMC Free Full Text] [BMC Free Full Text]

45. Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta-analysis. J Trauma Acute Care Surg 2012;73:261-8. [Medline]

46. Sun JH, Shing R, Twomeyc M, Wallis LA. A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa. Injury (2012), http://dx.doi.org/10.1016/j.injury.2012.08.015 (in press) [Medline]

47. Bidgoli HH, Hasselberg H, Khankeh H, Zavareh DK, Johansson E. Barriers and facilitators to provide effective prehospital trauma care for road traffic injury victims in Iran: a grounded theory approach. BMC Emerg Med 2010, 10: 20. Available at http://www.biomedcentral.com/1471-227X/10/20 (Accessed Jan11, 2013). [Medline] [PMC Free Full Text] [BMC Free Full Text]

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 71

cAse RePoRT

successful intubation with air-Q in Pierre Robin syndromeTariq Hayat Khan, FCPS*, Amna Ghayas**, Ayesha**, Samreen Khushbakht***, Adeel Ahmed***, Naeem Khan, FRCS****

*Consultant anesthesiologist; **Postgraduate traineeDepartment of anesthesiology, KRL General Hospital, G-9/1, Islamabad (Pakistan)

***Postgraduate trainee; ****Professor & HoDDepartment of pediatric surgery, KRL General Hospital, G-9/1, Islamabad (Pakistan)

Correspondence: Dr. Tariq Hayat Khan, FCPS, Consultant anesthesiologist, H. No. 163, Street 53, G-10/3, Islamabad (Pakistan); Cell: +92 321 5149709; E-mail: tariqhayatkhan@hotmail.com

SUMMARYAirway access is particularly difficult in infants and children with some anatomical deformities, usually associated with congenital syndromes. Craniofacial abnormalities are commonly seen in the Pierre Robin Syndrome (PRS), Treacher Collins and Goldenhar syndromes. The Pierre Robin sequence consists of micrognathia and relative macroglossia with or without cleft palate. In the severe case, airway obstruction and feeding difficulties are present. Endotracheal intubation may be difficult, or in some case even impossible. We present a case report of intubation of a child, suffering from PRS, by using air-Q, a new intubating LMA, and use of tongue stitches to maintain airway during recovery.

Key words: Pierre Robin Syndrome; Pierre Robin sequence; Craniofacial abnormalities; Micrognathia; Macroglossia; Glossoptosis; Air-Q intubating laryngeal mask airway; Tongue stitches; Intubation

Citation: Khan TH, Ghayas A, Ayesha, Khushbakht S, Ahmed A, Khan N. Successful intubation with air-Q in Pierre Robin syndrome. Anaesth Pain & Intensive Care 2013;17(1):71-74

INTRODUCTION Pierre Robin Syndrome (PRS) is a congenital syndrome, consisting of multiple anomalies, including, micrognathia, receding and short mandible, cleft lip and/or palate. These children are either diagnosed before birth with the help of USG or immediately after birth. They have to undergo multiple surgeries, which usually have to be performed under general anesthesia. The major problem in PRS, which is faced by anesthesia team, is maintenance of airway due to glossoptosis resulting in obstructive sleep apnea (OSA). The anatomic obstruction along the entire airway can lead to cardio-pulmonary arrest and even death.1–3

We present a case report of successful management of airway in a one and half year old child, suffering from PRS and scheduled to undergo closure of her cleft palate. We intubated him with the help of air-Q intubating laryngeal mask airway (ILMA) or masked laryngeal airway, and had to use tongue sutures to keep the airway patent. CASE REPORTA two years old baby girl, weighing 8 kg, reported

for repair of her cleft palate under general anesthesia. Since birth she had had feeding problems due to her congenital anomalies. The only way of feeding for the initial fourteen months had been through her nasogastric tube, which had to be replaced after every few days. She had recurrent chest infections due to repeated aspirations. For the previous ten months she could tolerate small liquid feeds, but no solids. She was a known case of PRS, had short receding jaw and mouth opening limited to 1″ cm, tongue was large, plastered to the mouth floor and retracted posteriorly. There was no other associated congenital abnormality. The breathing was labored and noisy due to obstruction of the airways by bulky tongue and her resting SpO2 was 90% on room air. An attempt to visualize the oral structures failed due to lack of cooperation by the crying child. Her blood count was normal and Hb was 11.2 gm/dl, WBC count 14.9, RBC count 5.03 and hematocrit 36. Her echocardiography revealed no abnormality of her heart. She was anticipated to be a particularly difficult case as regard to airway management.In the operating room, inj. atropine 0.2 mg was given IV and infusion was started. She was planned to be

72 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

successful intubation with air-Q in Pierre Robin syndrome

anesthetized by inhalational technique, without loosing spontaneous respiration. Sevoflurane in 100% oxygen was administered through face mask, starting with 3% and gradually increasing to 8%. Standard monitoring was attached. When adequate depth of anesthesia was achieved, laryngoscope McIntosh blade No. 1 was tried to be inserted in the oral cavity but failed to advance beyond a few centimeters. An attempt with Miller blade also failed. There was just not sufficient space within her oral cavity to accommodate the laryngoscope blade. The child was continued to be ventilated by face mask, although full effort was required to keep her mouth open by pushing her mandible downward and forward. An i-gel No. 1.5 was then inserted and the anesthesia circuit attached to it. The child was now easily ventilated even by manual compression of the reservoir bag. But the surgery could not be accomplished with i-gel within the pharynx. Then air-Q No. 1.5 was brought in, prepared and inserted. The cuff was inflated. The circuit was attached and successful manual ventilation was confirmed by capnography and by chest auscultation. After ventilation for five minutes with sevoflurane in 100% oxygen, the circuit and the connector of the air-Q were removed, and a well-lubricated endotracheal tube (ETT) No. 3.5 was inserted through the proximal end of the air-Q. It was felt to pass through the glottis, its cuff inflated to 25 cmH2O pressure and the circuit was attached. Again successful manual ventilation was confirmed by capnography and by chest auscultation. The cuff of air-Q was then deflated, the connector of the ETT was removed and the removal stillet inserted in the proximal end of the ETT. Keeping the stillet as well as the ETT steady, the air-Q was pulled out. Manual ventilation was resumed through the ETT

and equal air entry confirmed bilaterally. The child was paralysed with inj. atracurium 5 mg IV. Inj. nalbuphine 2 mg and inj. midazolam 1 mg were given IV. Mechanical ventilation was started in PCV mode, respiratory rate of 25-30/min, I:E ratio 1:1.5, FiO2 of 50% and sevoflurane 2-3%. The surgery lasted for about thirty minutes, after which the anesthetic agent

was stopped and the child was ventilated with 100% oxygen. Respiratory rate and the inspiratory pressures were gradually decreased so as to let CO2 build up to 40-45%. On resumption of spontaneous breathing

effort, neostigmine and glycopyrrolate were given. The child maintained adequate tidal volume on spontaneous breathing and the recovery went smooth until extubation was done, when she started crying. The surgeon demanded that the child be kept calm and stress free, to avoid bleeding from the surgical site. Hence, she was sedated with inj. midazolam 0.5 mg IV, after which upper airway obstruction by the tongue was noted and SpO2 dropped to 80%. Airway was only partly patent even by forceful jaw holding. To raise SpO2 from 90% to ≥95%, air-Q was reinserted, anesthesia circuit attached and 100% O2 given. This cycle was repeated three times. Every time air-Q was removed and the child allowed to resume full recovery, she cried; and every time she was sedated, her SpO2 fell due to airway obstruction by the tongue. The surgeon was requested to intervene and stitch the tongue outside. He stitched it at two places through the alveolar margins pulling it forward, after which the stridor was terminated and the child maintained SpO2 despite being sedated. She was then shifted to the pediatric ICU for postoperative care. The stitches in the tongue were removed the next day and she was discharged after few days.

DISCUSSIONAirway management and endotracheal intubation in children usually present no difficulties for the experienced anesthesiologists. In infants, access may be slightly more problematic because of certain anatomical variations. Airway access is particularly difficult in infants and children with some anatomical deformities, usually associated with congenital syndromes. Craniofacial abnormalities are commonly seen in the PRS, Treacher Collins and Goldenhar syndromes. The Pierre Robin sequence consists of micrognathia and relative macroglossia with or without cleft palate. In the severe case, airway obstruction develops in the first four weeks of life.4 When the baby is supine the tongue will fill the nasopharynx (via the cleft palate if present) and cause varying degrees of airway obstruction. In our case the child had all of the classical signs of PRS, so a difficult airway was anticipated at the time of pre-anesthesia assessment.5 We took all the appropriate precautions to deal with adverse situation. While pre-operative sedation of the pediatric patients remains individual choice, it’s common for anesthesiologists to give oral premedication to reduce perioperative anxiety, ease induction, and increase parental satisfaction.6,7 We chose not to sedate her preoperatively, due to uncertain timing of the surgery and inadequate protocols for transferring pediatric patients from the ward to the operating rooms.The repair of the cleft palate necessitates the choice of general anesthesia with intubation. The airway is shared by the anesthesiologist and the surgeon, so we cannot

Figure 1: ETT in place through the air-Q

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 73

case report

opt for the laryngeal mask airway (LMA) or i-gel, as both these devices fill the small buccal cavity leaving no space for the surgical maneuvers. The combination of severe micrognathia and relative macroglossia and the cephalad placement of the larynx can make the larynx almost invisible with conventional equipment. Some authors have advocated awake LMA insertion followed by inhaled induction of anesthesia in neonates with the PRS and severe upper airway obstruction presenting for glossopexy or mandibular distraction.8,9 This option cannot be exercised in pediatric cases due to lack of cooperation.In similar situations in an adult patient an awake fibreoptic technique would often be advocated, but this cannot be done in children since cooperation is required to gain good bronchoscopic views. Pediatric flexible fibreoptic bronchoscope was available with us, but its use in an emergency requires considerable expertise and practice. Atropine premedication was administered to dry up secretions and to counteract bradycardia due to vagal stimulation. We used oxygen with sevoflurane by a spontaneous breathing method. Muscle relaxants were withheld until the airway was secure. Intubation was performed under deep inhalational anesthesia for fear of loss of airway. Use of a muscle relaxant during induction of anesthesia may result in a situation where one can neither manually inflate the patient’s lungs nor intubate, and must therefore gain a surgical airway rapidly. Maintenance of spontaneous breathing allowed us a way out, should the airway had proved impossible to secure.10

The use of a supraglottic airway device for the management of a difficult airway and as a conduit for tracheal intubation is recommended by many guidelines, e.g. that of the American Society of Anesthesiologists.11 In the meantime a multitude of such devices has been developed and made commercially available.It is usually impossible to insert even the smallest Macintosh or Miller blades in the pharynx for intubation in these children. The alternatives available are blind intubation, the use of conventional LMA or i-gel or intubating LMA. Blind intubation may be associated with a high incidence of failure and the risk of hypoxia. Intubation through LMA Classic or i-gel, although mentioned in the literature, but is not favoured due to low rate of success. The original intubating laryngeal mask airway (Fastrack) was specifically designed to facilitate intubation without using a laryngoscope in difficult cases, however, it is not available in our country. Recently another similar device has been launched with the name of air-Q (Cookgas, St. Louis, Missouri, USA). Its design includes a curved shaft, the lack of a grill in

the ventilating orifice and an easily removable airway adapter. However, reports and studies concerning this device are scarce in the literature.12,13 The air-Q ILA offers several advantages in children over traditional laryngeal masks, the most significant being the ability to pass an ordinary cuffed tracheal tube through its airway tube, although it failed to be reliable facilitators for blind intubation. In contrast, the Fastrach ILMA had a 95% success rate and proved to be the best approach among those tested for securing the airway and facilitating blind intubation. The additional use of a fibrescope led to a near-100% success rate.14 But it requires special, purpose built ETT to be used with it. The air-Q has shown a performance similar to the Cobra-PLUS regarding quality of ventilation, but was slightly better for blind intubation. However, 43% failed attempts seems rather high considering that this device is used in an emergency setting.15 Traumatisation by supralaryngeal airways and blind intubation have been described in the literature.16-18 A new generation air-Q has been described to be more efficient in intubation.19

We successfully used air-Q for intubation in our patient in first attempt and atraumatically. An ordinary cuffed ETT was used and the air-Q was removed over the tube easily.During recovery, sedation is advisable to keep the child cool and calm and avoid bleeding and aspiration. The sedation, on the other hand, causes tongue to lose tone and results in respiratory obstruction even in lateral or prone position in PRS patients. Some maneuvers described to overcome this obstruction include insertion of small diameter tubes (or nasal airways if available in suitable size) through both of the nostrils and/or tying tongue to the chin.20 In a survey based study conducted via e-mail to 2080 members of the American Cleft Palate-Craniofacial Association, with a total of 396 responders, tongue suture in postoperative airway management of the cleft palate patient was used by 41.1% of the respondents, equal to those who never used it.21 In our case the surgeon tied the tongue at two points with silk passing through the alveolar ridges (gums). Both these methods are useful and the child can be kept sedated. In extreme cases, these children are best nursed prone, but surgical intervention such as tracheostomy, bilateral mandibular distraction or glossopaxy may prove necessary.4,22

CONCLUSIONAirway maintenance during anesthesia is the prime duty of the anesthesiologists, and air-Q ILMA as well as tongue stitches can provide great help and come to their rescue in difficult cases like Pierre Robin syndrome.

74 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

successful intubation with air-Q in Pierre Robin syndrome

1. Tomaski SM, Zalzal GH, Saal HM. Airway obstruction in the Pierre Robin sequence. Laryngoscope.1995;105:111–4. [PubMed]

2. Guilleminault C. Obstructive sleep apnea syndrome and its treatment in children: Areas of agreement and controversy. Pediatr Pulmonol. 1987;3:429–36. [PubMed]

3. Cohen SR, Simms C, Burstein FD, Thomsen J. Alternatives to tracheostomy in infants and children with obstructive sleep apnea. J Pediatr Surg. 1999;34:182–6. discussion 187. [PubMed]

4. Gözü A, Genç B, Palabiyik M, Unal M, Yildirim G, Kavuncuoğlu S, Ozsoy Z. Airway management in neonates with Pierre Robin sequence. Turk J Pediatr. 2010 Mar-Apr;52(2):167-72. [Medline]

5. Smith MC, Senders CW. Prognosis of airway obstruction and feeding difficulty in the Robin sequence. Int J Pediatr Otorhinolaryngol. 2006 Feb;70(2):319-24. [Medline] Epub 2005 Aug 19.

6. Barone CP, Pablo CS, Barone GW. Postanesthetic care in the critical care unit. Crit Care Nurse. 2004;24(1):38-45.[Context Link]

7. Jordi M, Elena C, Anna H. Evidence for the use of a numerical rating scale to assess the intensity of pediatric pain. EurJ Pain. 2009;13(10):1089-1095. [Context Link]

8. Markakis D, Sayson S, Schreiner M. Insertion of the laryngeal mask airway in awake infants with the Robin sequence. Anesth Analg 1992; 75: 822–824. [Medline] [Free Full Article]

9. Stricker P, Budac S, Fiadjoe J et al. Awake laryngeal mask insertion followed by induction of anesthesia in infants with the Pierre Robin sequence. Acta Anaesthesiol Scand 2008; 52:

1307–1308. [Medline] doi: 10.1111/j.1399-6576.2008.01751.x.

10. Walker RWM. Management of the difficult airway in children. J R Soc Med. 2001 July;94(7):341–344. [Medline]

11. Benumof JL. ASA difficult airway algorithm. New thoughts and considerations. In: Hagberg CA, editor. Handbook of difficult airway management. Philadelphia: Churchill Livingstone; 2000. pp. 31–48.

12. Yang D, Deng XM, Tong SY, et al. Fiberoptic intubation through Cookgas intubating laryngeal airway in two children. Anaesthesia 2009; 64:1148–1149. [Medline] doi: 10.1111/j.1365-2044.2009.06097.x.

13. Jagannathan N, Roth AG, Sohn LE, et al. The new air-Q intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series. Pediatr Anaesth 2009; 19:618–622. [Medline]

14. Fiadjoe JE, Stricker PA. The air-Q intubating laryngeal airway in neonates with difficult airways. Pediatr Anesth 2011;(21):702-3 [Medline] doi: 10.1111/j.1460-9592.2011.03558.x.

15. Erlacher W, Tiefenbrunner H, Ka¨ stenbauer T, Schwarz S, Fitzgerald RD. CobraPLUS and Cookgas air-Q versus Fastrach for blind endotracheal intubation: a randomised controlled trial. Eur J Anaesthesiol 2011;28:181–186 [Medline] doi: 10.1097/EJA.0b013e328340c352.

16. Turan A, KayaG, KoyuncuO, et al. Comparison of the laryngeal mask (LMA) and laryngeal tube (LT) with the new perilaryngeal airway (CobraPLA) in short surgical procedures. Eur

J Anaesthesiol 2006; 23:234–238. [Medline]17. Akca O, Wadhwa A, Sengupta P, Durrani J,

Hanni K, Wenke M, et al. The new perilaryngeal airway (CobraPLUS™) is as efficient as the laryngeal mask airway (LMA™) but provides better airway sealing pressures. Anesth Analg 2004; 99:272–278. [Medline]

18. van Zundert A, Al-Shaikh B, Brimacombe J, Koster J, Koning D, Mortier EP. Comparison of three disposable extraglottic airway devices in spontaneously breathing adults: the LAM-Unique, the Soft Seal Laryngeal Mask, and the Cobra perilaryngeal airway. Anesthesiology 2006; 104:1165–1169. [Medline]

19. Joffe AM, Liew EC, Galgon RE, Viernes D, Treggiari MM. The second-generation air-Q intubating laryngeal mask for airway maintenance during anaesthesia in adults: a report of the first 70 uses. Anaesth Intensive Care. 2011 Jan;39(1):40-5. [Medline]

20. Dorfman DW, Ciminello FS, Wong GB. Tongue suture placement after cleft palate repair. J Craniofac Surg. 2010 Sep;21(5):1601-3. [Medline] doi: 10.1097/SCS.0b013e3181ebccb1.

21. Bath AP, Bull PD. Management of upper airway obstruction in Pierre Robin sequence. J Laryngol Otol. 1997 Dec;111(12):1155-7. [Medline]

22. Meyer AC, Lidsky ME, Sampson DE, Lander TA, Liu M, Sidman JD. Airway interventions in children with Pierre Robin Sequence. Otolaryngol Head Neck Surg. 2008 Jun;138(6):782-7. [Medline] doi: 10.1016/j.otohns.2008.03.002.

REFERENCES

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 75

cAse RePoRT

Anesthetic considerations in Morquio syndrome: A case report Thorat Pravin Shivajirao, MBBS, DA, DNB*, Nageshkumar P Wasmatkar, MBBS**, Pratibha Govindrao Gore, BDS***, J. N. Lakhe, MBBS, B.Sc., MD****, Shidhaye Ramchandra Vinayak, MD, DA*****

*Assistant Professor; **Postgraduate Resident; **** Associate Professor; *****Professor Department of Anesthesiology and Critical Care Rural Medical College, Pravara Institute of Medical Sciences, Loni 413736 (India)

***Postgraduate Resident Department of Oral Pathology and Microbiology Rural Dental College, Pravara Institute of Medical Sciences, Loni 413736 (India)

Correspondence: Dr. R. V. Shidhaye, Shraddha Clinic, Babhaleshwar, Tal. Rahata, Distt. Ahmednagar- 413737 (India); Phone: 02422 253459; Cell: 091 9822034601; E-mail: rvshidhaye@yahoo.com

ABSTRACT Anesthetic challenges in Morquio syndrome include the respiratory problems due to restrictive defect in the thoracic cage, upper airway obstruction during head flexion, atlantoaxial instability and compression of the cervical spinal cord due to hypoplasia of the dens, complicating intubation. After pre-anesthetic check up and informed written consent, the patient was premedicated with glycopyrrolate 0.08 mg and fentanyl 10 mcg. Induction was done with inhalational anesthetic agent sevoflurane along with Oxygen (O2) and Nitrous oxide (N2O) maintaining the spontaneous respiration. Intubation was done with Flexo metallic tube (FMT) no. 24 through right nostril avoiding forceful movements at atlantoaxial joint and cervical spine. Maintenance and recovery was uneventful. Paramount in the anaesthetic care of such patients is a thorough preoperative evaluation of airway in addition to cardiac, respiratory, neurological function. Inhalational induction technique may be useful in difficult intubation.

Key words: Morquio syndrome; Inhalation induction; Difficult intubation

Citation: Thorat PS, Wasmatkar NP, Gore PG, Lakhe JN, Shidhaye RV. Anaesthetic consideration in Morquios syndrome: Case report. Accepted for publication in Anaesth Pain & Intensive Care April 2013; 17(1) 75-78

INTRODUCTIONMucopolysaccharidoses are a heterogeneous group of metabolic disorders usually inherited in autosomal recessive fashion, characterized by a lack of glycosaminoglycans. Mucopolysaccharidosis type IV is an autosomal recessive disorder caused by deficiency of n- acetylgalactosamine-6-sulphate and is also called as Morquio syndrome.1 It is characterized by a defect in the degradation of keratan sulfate resulting in the accumulation of mucopolysaccharides. The disorder results in short stature, spinal deformity, odontoid hypoplasia, macroglossia, corneal opacities, short neck, pectus carinatum, kyphoscoliosis, dwarfism, cardiac abnormalities, hepatomegaly, acoustic deafness, and dental abnormalities.2 Atlantoaxial subluxation and cervical myelopathy are usual clinical findings. Anaesthetic challenges in such cases include the

respiratory problems due to, restrictive defect in the thoracic cage, upper airway obstruction during head flexion, atlantoaxial instability and compression of the cervical spinal cord due to hypoplasia of the dens; complicating intubation procedures.

CASE REPORTA male patient, 17 years, weighing 18 kg, presented to the pedodontics department with dental caries for full mouth rehabilitation. He was born of consanguineous marriage with full term normal vaginal delivery with birth weight of 1.75 kg and history of birth asphyxia. He had delayed speech and had been very hyperactive. Clinical examination revealed a short stature, microcephaly, short neck, cervical scoliosis, slanting forehead, barrel chest deformity, dorsolumbar kyphosis, increased anteroposterior diameter of chest,

76 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

anesthetic considerations in Morquio syndrome

3 and 4) showed ‘mild flaring and widening of ribs, platyspondyly ( flattening of vertebral bodies) and anterior beaking of all vertebrae, short thick clavicles, pectus carinatum (increase in AP distance of thoracic cage), focal narrowing of airway seen at the level of hypopharynx just posterior to epiglottis measuring 5mm at this level, 10mm above it and 15mm below it in AP diameter and hypoplastic maxilla with prominent mandible.

Figure 1: Side view of the child

Figure 2: Front view of the child

pectus excarinatum, waddling gait, pot belly, valgus deformity of both upper and lower limbs and hoarse voice (Figures 1 and 2). Oral cavity examination revealed bulky soft tissue, large tongue, caries teeth, poor oral hygiene, large uvula and restricted neck anteroposterior movements, Mallampati grade– II. Systemic examination showed normal cardiovascular and respiratory systems. Liver was palpable by 1½ cm below right costal margin. Preoperative investigations, including hemogram, urine examination, liver function tests, renal function tests and echocardiography were within normal limits. X-ray neck and cervical spine AP view( Figure 3) showed ‘thickening of calvarium, hypoplasia of odontoid process of C2 vertebra, atlanto-occipital subluxation (lateral atlanto-dental distance: on left side-2.6mm and on right side- 1.25mm; Predental distance: anteriorly-2.58mm and posteriorly-4.30mm). Chest x-ray PA view and lateral view with skull (Figures

Figure 3: Chest x-ray PA view Figure 4: Lateral view of the skull and cervical spine

Figure 5: Lumbosacral spine lateral view showing poorly visualized femoral capital epiphyses, increased interpeduncular distance, flattening of the vertebral bodies anteriorly

Figure 6: Lumbosacral spine AP view

Figure 7: Wrist joints AP view showed mild widening of metacarpals and slanting distal articular surfaces of radius and ulna

Lumbosacral spine x-rays on AP and lateral views (Figures 5 and 6) showed ‘ not clearly visualized femoral capital epiphyses (progressive disappearance is characteristic), flaring of iliac wings, increased obliquity of acetabular roof, interpeduncular distance increasing caudally in lumbosacral spine. Wrist joint AP view (Figure 7) showed mild widening of metacarpals and slanting distal articular surfaces of radius and ulna. Constellations of all these radiological findings favored the

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 77

case report

clinical suspicion of ucopolysaccharidosis and possibility of difficult intubation.Anaesthetic management: General anaesthesia was planned with sevoflurane in oxygen and nitrous oxide. Glycopyrrolate was given, but no heavy sedation, as premedication. Considering the anticipated difficult intubation inhalational induction with spontaneous respiration was planned. Due to a possibility of atlantoaxial subluxation and cervical myelopathy intubation was planned with neck stabilization. Nasal intubation was planned with a flexometallic tube, as the dental surgeon had to share airway and oral cavity. Use of flexible bronchoscope for intubation was the good option but it was not available. Extubation was planned to be done when patient was full conscious and awake, considering the possibility of respiratory depression and difficult intubation if reintubation was required. Postoperatively intensive monitoring for airway patency and adequacy of respiration and hemodynamic stability was planned. After pre anaesthetic check up and informed written consent, patient was premedicated with glycopyrrolate 0.08 mg and fentanyl 10 mcg. Induction was done with inhalational anaesthetic agent sevoflurane in oxygen and nitrous oxide. Sevoflurane was increased in incremental doses from 2% to 8%. After achieving adequate depth of anaesthesia with sevoflurane patient was intubated with flexometallic endotracheal tube No. 24 through right nostril, avoiding forceful movements at atlantoaxial joint and cervical spine and maintaining spontaneous respiration. Patient was maintained on sevoflurane in oxygen and nitrous oxide. Analgesia was provided with incremental doses of inj. fentanyl. Monitoring included heart rate, electrocardiogram, non invasive blood pressure, oxygen saturation (SpO2) and endtidal carbon dioxide. After completion of the surgical procedure the patient was extubated when fully awake and with all airway reflexes recovered. Patient was shifted to recovery room where he was monitored for the vital parameters. Recovery was uneventful and patient was shifted to pediatric ward after gaining full consciousness.

DISCUSSIONMorquio syndrome also known as mucopoly-saccharidosis type IV is an autosomal recessive disorder caused by deficiency of n-acetylgalactosamine-6-sulphate. Morquio in Uruguay and Brailsford in England simultaneously described this syndrome in 1929.1 The incidence is unknown but is estimated to be between 1 in 75 000 population in Northern Ireland to 1 in 200 000 population in British Columbia.3,4 Morquio syndrome is characterised by a defect in

the degradation of keratin sulphate resulting in the accumulation of mucopolysaccharides. At birth, a patient with Morquio syndrome may appear healthy; however, as the child grows into adulthood, various manifestations of this syndrome begin to emerge.The airway issues in these patients are frequently complicated by cervical spine instability and the risk of subluxation.5 Respiratory function can be compromised by chronic respiratory disease, recurrent pulmonary infections, obstructive sleep apnea and kyphoscoliosis leading to restrictive lung disease. The most important problems concerning the airway management are based on intracellular accumulation of mucopolysaccharides resulting in macroglossia, limited mouth opening due to involvement of temporo-mandibular joints and short neck. The trachea is often narrow and flattened.6 The unique anatomy and extremely sensitive airway may result in failed intubation and bronchospasm even after successful intubation.7 These elements may lead to ‘cannot intubate, cannot ventilate’ situation. Cardiac involvement is usual. Valve involvement may cause incompetent or stenotic lesions especially of the aortic valve,8,9 whilst myocardial deposits cause reduced compliance.8 Systemic and pulmonary hypertension may occur and death is often due to cardiac or respiratory failure.10 In our patient, we noticed coarse facial features like frontal slanting, narrowed nasal opening, macroglossia, reduced oropharyngeal space, dental caries, restricted neck movements and the skeletal abnormalities like kyphoscoliosis contributing to difficult ventilation and intubation. Cardiac abnormalities, e.g. aortic regurgitation and other valvular lesions, were not present in our case. Premedicants are best avoided because of dangers of upper airway obstruction, respiratory depression, hypercarbia and cardiorespiratory arrest. An antisialogogue is an essential component of preanaesthetic medication in view of the copious upper airway secretions, and antibiotic prophylaxis is advised in view of the high incidence of cardiac valvular lesions.11 We used glycopyrrolate as an antisialogogue and avoided sedative agents. We gave titrated doses of fentanyl under strict respiratory monitoring. An inhalational induction with sevoflurane provides a controlled situation with maintenance of spontaneous ventilation until laryngoscopy is performed. Depth of anaesthesia can be titrated by adjusting concentration of inhalational agent. The main advantage of using inhalational induction is that it keeps the returning doors open in ‘cannot intubate, cannot ventilate’ situation. We took care of the cervical spine by limiting the neck movements and stabilizing it during induction and intubation throughout the procedure. Sevoflurane was chosen as inhalational agent because

78 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

anesthetic considerations in Morquio syndrome

it is non-irritant, tolerated well by children and gives fast induction and recovery. If muscle relaxation is felt necessary, provided the lungs can be ventilated adequately, suxamethonium provides the best intubating conditions.10 The controversy regarding the appropriate mode of induction still exists. Some anesthesiologists prefer the use of intravenous agents, while others choose inhalational agents (especially in children), but most of the authors suggest avoiding muscle relaxants. The relaxation of the supraglottic tissue may preclude effective bag-mask ventilation.12

Endotracheal intubation using fiberoptic technique, being minimally invasive and allowing neutral head position is strongly recommended in these patients.13

Oral fiberoptic technique might be difficult due to large, heavy, anteriorly placed, ‘hanging epiglottis’ (sometimes resting on the tongue base) making the passage of the

fiberscope impossible. Nasal fiberoptic technique may also be difficult related to mucopolysaccharoid infiltration in the nasopharynx, with the increased risk of bleeding.14 Fiberoptic bronchoscope may not be available at most canters and it also requires special skills.

CONCLUSIONUnderstanding the Morquio syndrome and careful planning of the anesthetic technique enables us to manage such patients successfully. A thorough preoperative evaluation of the airways, careful assessment of cervical spine, cardiac, respiratory and neurological functions are paramount in the anesthetic care of such patients. Inhalational induction may be useful to overcome the problem of difficult intubation when fiberoptic intubation is not possible.

1. Morquio L. Sur une forme de dystrophie osseuse familiale. Arch Med Enfants 1929; 32:129-140.

2. Holzgreve W, Gröbe H, von Figura K, Kresse H, Beck H, Mattei JF. Morquio syndrome: clinical findings in 11 patients with MPS IVA and two patients with MPSIVB. Hum Genet1981;57:360–5. [Medline]

3. Lowry RB, Renwick DH. Relevant frequency of the Hurler and Hunter syndromes. N Engl J Med1971;284:221-222. [Medline]

4. Nelson J. Incidence of the mucopolysaccharidoses in Northern Ireland. Hum Genet1997;101(3):355-8. [Medline]

5. Gösele S, Dithmar S, Holz FG, Völcker HE. Late diagnosis of Morquio syndrome. Clinical histopathological findings in a rare mucopolysaccharidosis. Klin Monbl Augenheilkd 2000;217(2):114-117. [Medline]

6. Walker RW, Darowski M, Morris P, Wraith JE. Anaesthesia and mucopolysaccharidoses. Anaesthesia1994;49:1078-84. [Medline]

7. Man TT, Tsai PS, Rau RH, Cheng CR, Ko YP, Wu KH. Children with mucopolysaccharidoses– three cases report. Acta Anaesthesiol Sin 1999;37:93-96. [Medline]

8. Renteria VG, Ferrans VJ, Roberts WC. The heart in the Hurler syndrome. Am J Cardiol1976;38:487-501. [Medline]

9. Ireland MA, Rowlands DB. Mucopolysaccharidosis type 4 as a cause of mitral stenosis in an adult. Br Heart J 1981;46:113-15. [Medline] [Free PMC Article]

10. King DH, Jones RM, Barnett MB. Anaesthetic considerations in the Mucopolysaccharidoses. Anaesthesia1984;39:126-31. [Medline]

11. Diaz JH, Belani KG. Perioperative management of children with mucopolysaccharidosis. Anesth Analg 1993; 77:1261-70. [Medline]

12. Tobias JD. Anesthetic care for the child with Morquio syndrome: general versus regional anesthesia. J Clin Anesth 1999;11(3):242-246. [Medline]

13. McLaughlin AM, Farooq M, Donnelly MB, Foley K. Anaesthetic considerations of adults with Morquio syndrome - a case report. BMC Anesthesiol 2010 Feb 26;0:2. doi: 10.1186/1471-2253-10-2. [Medline] [Free PMC Article]

14. Kadic L, Driessen JJ. Driessen:General anaesthesia in an adult patient with Morquio syndrome with emphasis on airway issues. Bosn J Basic Med Sci 2012;12(2):132-133. [Medline]

REFERENCES

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 79

cAse RePoRT

challenges during prolonged mechanical ventilation of a morbidly obese lady with hypothyroidism and sleep apnea syndromeSaurabh Kumar Das, MD*, D. K. Singh, MD**, Sujali Choupoo, MD*, Ghanshyam Yadav, MD***

*Senior Registrar; **Professor; ***Assistant ProfessorInstitute of Medical Science, Banaras Hindu University, Varanasi, Uttar Pradesh (India)

Correspondence: Dr Saurabh Kumar Das, Intensive Care Unit, SS Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh (India); E-mail – drsauravdas1977@gmail.com

ABSTRACTObesity, sleep apnea syndrome and hypothyroidism cause management of mechanical ventilation and weaning a difficult task. We report management of mechanical ventilation and subsequent weaning of a morbidly obese lady of BMI 42 kg/m2 with hypothyroidism and sleep apnea for 52 days. To make the matter worse, she had accidental extubations, multiple cardiac arrests, pneumonia and renal dysfunction during her ICU stay.

Key words: Mechanical ventilation; Morbidly obese; Obesity; Sleep apnea syndrome; Hypothyroidism; BMI; Accidental extubation

Citation: Das SK, Choupoo S, Yadav G. Challenges during prolonged mechanical ventilation of a morbidly obese lady with hypothyroidism and sleep apnea syndrome. Anaesth Pain & Intensive Care 2013;17(1):79-82

INTRODUCTIONMechanical ventilation poses tremendous challenges in obese patients. We describe how we successfully ventilated a morbidly obese lady of BMI 42 kg/m2

with hypothyroidism and sleep apnea for 52 days and whose ICU stay was complicated by accidental extubation, multiple cardiac arrests, pneumonia and renal dysfunction.

CASE REPORTA 56 years old lady was posted for emergency exploratory laparotomy for obstructed incisional hernia. She presented with complaints of pain abdomen, vomiting and retention of stool and flatus for the last five days. She was known to have hypothyroidism, sleep apnea and day time somnolence for many years. She undergone hysterectomy few years back, which remained uneventful.Important positive findings in pre anesthetic checkup were as follows; The lady had a weight of 110kg and BMI 42kg/m2. Her Glasgow coma scale was E4V4M4; SpO2 was 90% on room air; PO2 55 mmHg. Laboratory investigations revealed her serum creatinine 4.5mg/dl and blood urea to be 65mg/dl. On chest auscultation breath sound were reduced on left side. ECG showed

ST segment depression in V3, V4, V5 leads. Her chest x-ray revealed left lower zone infiltration.It was planned to conduct the operation under general anesthesia combined with lumber epidural for intra-operative and post operative analgesia. Before induction epidural catheter was placed in L2L3 intervertebral space. After giving test dose and confirming negative aspiration, 0.25% of 5ml bupivacaine was given slowly. Immediately after giving the local anesthetics, the patient developed bradycardia and asystole. CPR was started and airway was secured with endotracheal tube. After 3minutes of CPR the patient regained normal sinus rhythm and but had hypotension which was managed by noradrenaline infusion. The operation was deferred and patient was transferred to ICU. On ICU she was put on synchronized intermittent mandatory ventilation (SIMV) and pressure support(PS) ventilation with a Datex Ohmeda ventilator. Initial ventilator settings were as follows;Mode: SIMV + PSTidal volume(VT): 400ml (predicted body weight 45kg),Pressure support (PS): 14 mmHgPEEP: 4 mmHg,

80 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

challenges during prolonged mechanical ventilation

Box 1: Diary of events during IcU stayDay 2: Hemodynamic was maintained with noradrenaline infusion @ 5mcg/min GCS: E2VtM4, Temperature: 100oF, total leucocyte count: 14000/cmm. APACHE score was 18 (25% predicted mortality) Chest xray : left sided pneumonia, 2D echocardiography: right ventricular hypertrophy. Patient was operated on that day under general anesthesia. A portion of devitalized jejunum was resected, end to

end anastomosis was done and hernia was repaired. Intra-operative period was uneventfulDay 3: Temperature:103 oF, TLC : 15000 , RR: 28 -35/min, bronchospasm, percutaneous tracheostomy was done.Day 4: GCS: E3 VT M5 and Richmond Agitaion Sedation Score: 1, febrile for a couple of occasions. Clinical pulmonary infection score: >5 and SOFA (Sequential organ function assessment):10(33% mortality).Day 5: Patient self extubated and developed hypoxia and asystole. Patient was resuscitated within five minutes.Day 6, 7: Inj caspofungin was started (Candida score >2.5). There was radiological improvement of pneumoniaDay 8 to 13: There was radiological improvement of pneumonia. Patient looked more alert. Day 14: Had cardiac arrest. CPR was started with Autopulse, regained sinus rhythm within 6 minutesDay 15, 16: Unconscious, on vasopressor supportDay 17: Conscious but drowsy, serum creatinine and blood urea were 2.5 and 205 mg/dl respectively, ABG’s showed

metabolic acidosis with respiratory compensation. Continuous renal replacement therapy was given for 24 hours.

Day 18 to 33: Patient had several bouts of fever and occasional bronchospasm and tachypnea, Endotracheal and blood culture reports were sterile. GCS: E3 VT M5

Day 34: Put on PSV with PS of 14 cmH2O for 45 minutesDay 35 to 41: Duration of PSV was gradually increased.Day 42: Spontaneous breathing trial (SBT) was started.Day 43 to 49: Duration of SBT was increased gradually.Day 50: Tolerated SBT for three hours.Day 51: Put on T-piece.Day 52: Patient was extubated.Day 53, 54: Maintained oxygen supplementation by face mask @ 6 lit/min. Oxygen flow was reduced gradually.Day 55: Shifted from ICU with oxygen supplementation by nasal prongs.

Flow trigger at 2 lit/minFiO2: 1At these settings, peak inspiratory pressure (PIP) and plateau pressure (PPL) were 25-28 and 22 mmHg respectively. Dynamic and static compliance were 11-13 and 16 ml/mmHg respectively. No spontaneous effort was seen. Later on, Tidal volume (VT) and FiO2 were decreased to 350ml and 0.6 respectively to keep EtCO2 at 35 and SpO2 above 95%. ABG after two hours showed pH 7.25, PCO2 40 mmHg, HCO3 20, base excess -7, PO2 85 mmHg. Diary of events during patient’s ICU stay: The events which occurred or were observed in ICU are given as Box 1.After ventilating with SIMV + PS for seven days, her lung compliance remained low and unstable.PIP rose beyond 35 mmhg on number of occasions and set volume was not delivered. So, ventilator mode was changed to pressure control volume guarantee ventilation (PCV-VG) in following initial setting; Pmax: 35 cmH2O, VT 400 ml, RR: 15/min, FiO2: 0.4 - 0.6 and trigger: 2 lit/min.Patient had two episodes of cardiac arrest during her ICU stay; the first one on 5th ICU day when she pulled

out the tracheostomy tube by herself, and the second one on 14th day during suctioning her tracheostomy tube. Cardiopulmonary resuscitation (CPR) was started with load distributing noninvasive cardiac support pump (AutoPulse®; ZOLL® Medical Corporation, Chelmsford, MA-USA). During CPR, tracheostomy tube came out and an attempt to put it back pushed it through a false track. So the patient was intubated with a endotracheal tube size 7. She was revived within 6 minutes of cardiac arrest. Attendant of the patient declined to give consent for repeat tracheostomy.In next couple of days we tried to wean the patient off ventilation. The patient was put on pressure support ventilation at 18 mmHg. She became tachypneic, so pressure support was increased to 22 mmHg. Since tachypnea failed to resolve, she was put back on PCV-VG. Many attempts to put her back on PSV were without any success. After a month of ventilation, patient started tolerating short periods of PSV. On 34th ICU day, the patient was put on PSV with PS of 14 cmH2O for 45 minutes. Generated VT was 200-250 ml. PS was increased to 18 cmH2O. After 45 minutes, patient became tachypneic and restless. PaCO2 was 60 mmHg, so she was put back on PCV-VG mode. The next day, PSV was given for

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 81

case report

one hour before she became tachypneic. Duration of PSV was gradually increased for next 7 days and finally she was on PSV (PS 18cmH2O) for whole of the day on 41st ICU day. She remained stable throughout the day. RR and dynamic compliance were around 24 and 18 ml/cmH2O respectively. There was no fever during these days. TLC, DLC, serum creatinine and other investigations were within normal limits. PS was reduced to 15 cmH2O the next morning. We decided to start spontaneous breathing trial (SBT) in every morning. The patient was put on continuous positive airway pressure (CPAP) with PS 6 cmH2O and observed. She started having diaphoresis and tachypnea after ten minutes of SBT on first day of starting SBT, so PS was increased to 15 cmH2O. But within few days, Patient gradually started tolerating SBT for prolong periods. PS was slowly reduced to 10 cmH2O. On 50th ICU day, she tolerated SBT for three long hours. Next day, she was put on T-piece. Throughout the day, she was comfortable. ABG’s showed PO2 65 mmHg and PCO2 45 mmHg.Extubation was a difficult decision as her cough reflex was not satisfactory; she was a bit confused and not fully cooperative and there was previous history of sleep apnea as well. We planned to put her on noninvasive ventilation after extubation, if required. But in spite of all these adversaries, extubation was successful and she did not require noninvasive ventilation. Initially we gave her high flow oxygen with face mask with reservoir bag and non rebreathing valve. Physiotherapy and steam inhalations were given every two hours. Her post extubation ABG’s were normal. For the next three days, we reduced oxygen supplementation to 1L/min by nasal prongs. Finally, after fifty five days of ICU stay, fifty two days of ventilation, and three episodes of cardiac arrest she was shifted from ICU.

A summary of different modes of ventilation used for the patient is given in Table 1.

Table 1: Different modes of ventilation used

Days Ventilator Modes1-8 SIMV + PS9-13 PCV-VG and PSV14-33 PCV-VG34-40 PCV-VG and PSV41-51 PSV and SBT51 T-piece52 Successful extubation

Table 2: summary of obesity related respiratory changes

Change in respiratory parameter DescriptionDecreased compliance (chest wall >> lung) Reduced by as much as two-thirds of the normal due to increased pulmonary blood, accumulation

of fat in and around the ribs, the diaphragm and the abdomen2

Decrease in FEV1 to forced vital capacity (FVC) ratio, maxi-mal inspiratory flow rate

May be related to small airway collapse due to decreased lung volumes with increasing obesity.3,4

Increase work of breathing 70% more than normal.5

Respiratory muscle dysfunction Maximal voluntary ventilation (MVV) is reduced by 20% to 45% result from diaphragm dysfunction due to increased abdominal and visceral adipose tissue and fiber overstretching.1,5-6

Ventilation perfusion inequality Related to the degree of reduction in ERV, secondary to airway closure and alveolar collapse.1

Decreased compliance (chest wall>>lung) Reduced by as much as two-thirds of the normal due to increased pulmonary blood, accumulation of fat in and around the ribs, the diaphragm and the abdomen.2

Decrease in FEV1 to forced vital capacity (FVC) ratio, maxi-mal inspiratory flow rate

May be related to small airway collapse due to decreased lung volumes with increasing obesity.3,4

Increase work of breathing 70% more than normal.5

Respiratory muscle dysfunction Maximal voluntary ventilation (MVV) is reduced by 20% to 45% result from diaphragm dysfunction due to increased abdominal and visceral adipose tissue and fiber overstretching.1,5-6

Ventilation perfusion inequality Related to the degree of reduction in ERV, secondary to airway closure and alveolar collapse.1,5

Figure 1: Static lung compliance with days

DISCUSSIONObesity can adversely alter pulmonary function through its deleterious effect on respiratory mechanics, resistance within the respiratory system, respiratory muscle function, lung volumes, work and energy cost of breathing, control of breathing and gas exchange.[1]

We reviewed the obesity related respiratory changes and summarized in Table 2.

82 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

challenges during prolonged mechanical ventilation

Mechanical ventilation in obese patients:We ventilated the patient for 52 days. It has been observed that due to the mechanical and inflammatory alterations observed in obesity, this subgroup of patients usually needs prolonged ventilation.7 Mechanical ventilation in this population requires specific ventilator settings. We initially ventilated the patient with SIMV+PS than switched over to PCV-VG. No data suggest that any particular mode of ventilation is superior to any other mode in patients with obesity. Marik and Varon recommend calculating the initial tidal volume according to ideal body weight (IBW) and then making adjustments on the basis of airway pressures (plateau pressure) and the results of arterial blood gas analysis.8 In order to reduce lung stress and strain, as well as minimize the risk of ventilator associated lung injury, Leme Silva P et al suggested the following ventilator strategies:1. Stepwise recruitment maneuver before positive

end-expiratory pressure application, which requires titration according to respiratory system dynamic compliance.

2. Tidal volume (VT) titration according to inspiratory capacity.9

Gizella I. Bardoczky et al studied eight morbidly obese patients during general anesthesia and controlled mechanical ventilation and observed that increasing tidal volume although caused recruitment of alveolar units, but there was no significant improvement in oxygenation.10

Weaning from ventilation was a great challenge to us. It has been suggested that the reverse Trendelenburg position at 45° can facilitate the weaning process by allowing a larger tidal volume and lower respiratory

rates. El-Solh AA et al used noninvasive ventilation in immediate post-extubation period in 62 obese patients. They found significant reduction in post-extubation respiratory failure with a reduced length of ICU stay.11

We also considered noninvasive ventilation for our patient if patient had any respiratory difficulty after extubation. But fortunately, our patient did not require it.

We performed early tracheostomy anticipating need of prolonged mechanical ventilation. It is still debatable whether percutaneous tracheostomy is preferable to open surgical tracheostomy in obese patient. Ali A. ElSolh et al observed that morbid obesity is associated with increased frequency of life-threatening complications from conventional tracheostomy compare to control group.12 Percutaneous tracheostomy is also not without hazards. Various problems e.g. difficulty in identification of anatomical land marks, to obtain proper position and possibility of creating a false track may be encountered during percutaneous tracheostomy. Naresh G Mansharamani et al successfully performed percutaneous tracheostomy in 13 obese patients with the mean BMI of 45.9 ± 12.4 kg/m2.13

Our patient had also suffered from hypothyroidism which is commonly associated with obesity and is also a cause of prolonged ventilation. Datta D et al studied 140 patients receiving prolonged mechanical ventilation with failure to wean. 4% of these patients had hypothyroidism whose weaning was possible after thyroid supplements.14

We were lucky to sail through turbulent waters safely and successfully weaned off the patient after prolonged ventilation against all odds. Patience and persistent vigilance were the keys to the success.

1. Koenig SM. Pulmonary complications of obesity. Am J Med Sci. 2001 Apr;321(4):249-79 [Medline]

2. Naimark A, Cherniack RM. Compliance of the respiratory system and its components in health and obesity. J Appl Physiol. 1960 May;15:377-82. [Medline]

3. Rubinstein I, Zamel N, DuBarry L, Hoffstein V. Airflow limitation in morbidly obese, nonsmoking men. Ann Intern Med. 1990 Jun 1;112(11):828-32. [Medline]

4. Lazarus R, Sparrow D, Weiss ST. Effects of obesity and fat distribution on ventilatory function: the normative aging study. Chest 1997 Apr;111(4):891-8 [Medline].

5. Ray CS, Sue DY, Bray G, Hansen JE, Wasserman K. Effects of obesity on respiratory function. Am Rev Respir Dis 1983

Sep;128(3):501-6. [Medline]6. Sharp JT, Druz WS, Kondragunta VR.

Diaphragmatic responses to body position changes in obese patients with obstructive sleep apnea, Am Rev Respir Dis 1986 Jan;133(1):32-7 [Medline]

7. Ali El-Sohl et al. Morbid obesity in medical ICU, Chest. 2001;120(6):1989-1997. [Medline]

8. Marik P, Varon J. The obese patient in the ICU. Chest 1998;113:492–498 [Medline]

9. Leme Silva P, Pelosi P, Rocco PR. Mechanical ventilation in obese patients. Minerva Anestesiol 2012 Oct;78(10):1136-45. [Medline]

10. Gizella I. Bardoczky. Large Tidal Volume Ventilation Does Not Improve Oxygenation in Morbidly Obese Patients During Anesthesia. Anesth Analg 1995;81:385-8. [Medline]

11. El-Solh AA. Noninvasive ventilation for prevention of post-extubation respiratory failure in obese patients. Eur Respir J 2006 Sep;28(3):588-95. [Medline] [Free Full Text]

12. Ali A El Solh, Wafaa Jaafar. A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients. Critical Care 2007;11(1):R3. [Medline] [Free Full Text]

13. Mansharamani NG, Koziel H, Garland R, LoCicero J 3rd, Critchlow J, Ernst A. Safety of bedside percutaneous dilataional tracheostomy in obese patient in ICU. Chest 2000;117(5):1426-1429. [Medline]

14. Datta D, Scalise P. Hypothyroidism and failure to wean in patients receiving prolonged mechanical ventilation at a regional weaning center. Chest. 2004 Oct;126(4):1307-12. [Medline] [Free Full Text]

REFERENCES

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 83

cAse RePoRT

Dexmedetomidine and the perioperative care in Riley-Day syndrome: a case report and literature reviewMatthew DiGiusto, BA*, David Martin, MD**, Joseph D. Tobias, MD**

*The Ohio State School of Medicine, Columbus, Ohio (USA)**Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University, Columbus, Ohio (USA)

Correspondence: David Martin, MD, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, Ohio 43205 (USA); Phone: (614) 722-4200; FAX: (614) 722-4203; E-mail: David.Martin@Nationwidechildrens.org

ABSTRACT Familial dysautonomia (FD), also known as Riley-Day syndrome, is a disorder of the autonomic nervous system that results in loss of demyelinated nerve fibers of sensory, sympathetic and parasympathetic neurons. Individuals with FD have variable clinical symptoms that may include insensitivity to pain, inability to produce tears, poor oral intake during infancy, repeated vomiting, failure to thrive, wide fluctuations in body temperature, and episodic hypertension and hypotension. These paroxysmal crises are due to dysfunction of the autonomic system with an elevation of both norepinephrine and dopamine levels. Clonidine, an α2-adrenergic agonist, has been previously demonstrated to be an effective pharmacological agent in the treatment of dysautonomic crises related to FD. Dexmedetomidine is an α2-adrenergic agonist with an α2:α1 specificity that is almost 8 times that of clonidine. The authors present the perioperative use of dexmedetomidine in a patient with FD. Previous reports of the use of dexmedetomidine in patients with FD are reviewed and the beneficial physiologic effects discussed.

Key words: Familial dysautonomia; Riley-Day syndrome; Clonidine; Dexmedetomidine; Autonomic nervous system dysfunction; Hereditary sensory and autonomic neuropathies; Paroxysmal autonomic instability with dystonia; PAID

Citation: DiGiusto M, Martin D, Tobias JD. Dexmedetomidine and the perioperative care in Riley-Day syndrome: a case report and literature review. Anaesth Pain & Intensive Care 2013; 17(1):83-87

INTRODUCTIONFamilial dysautonomia (FD), originally known as Riley-Day syndrome, was first described by Riley and Day after a constellation of unique findings were noted in a group of patients who were Ashkenazi Jews.1 This original report included five children, whose clinical presentation included hypertension, erythematous cutaneous eruptions, excessive sweating, and defective lacrimation in response to anxiety. Today FD is recog-nized as one of a group of genetically distinct disorders known as Hereditary Sensory and Autonomic Neu-ropathies (HSAN). FD is a disorder of the autonomic nervous system that results in loss of demyelinated nerve fibers of sensory, sympathetic, and parasympa-thetic neurons. FD displays an autosomal recessive mode of inheritance from a single mutation on chro-mosome 9q31 in the gene coding inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase as-sociated protein complex (IKBKAP).2

Infants with FD have variable symptoms including in-sensitivity to pain, inability to produce tears, poor oral intake, repeated vomiting, failure to thrive, wide fluc-tuations in body temperature, and episodic hyperten-sion and hypotension.3 Given their multiple medical problems including poor oral intake, feeding intoler-ance and repeated episodes of vomiting, surgical inter-ventions may be required in these patients. Periop-eratively, patients with FD may manifest paroxysmal crises, most often attributed to emotional distress or pain, which include hypertension, tachycardia, vom-iting, fever, diaphoresis, and erythematous cutaneous eruptions.3 During these paroxysmal events, norepi-nephrine (NE) and dopamine levels are increased.4 It has been hypothesized that the hypertension occurring during these crises is due to the increased vascular sen-sitivity to released catecholamines as the blood vessels in patients with FD show an exaggerated response to NE.5 One of the goals of perioperative care is to limit

84 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

dexmedetomidine in Riley-Day syndrome

the sympathetic stress response and blunt the release of endogenous catecholamines.Dexmedetomidine is an α2-adrenergic agonist approved for sedation of adults during mechanical ventilation and for monitored anesthesia care (MAC) of adults. Although FDA approved it only for use in adults, it has been used successfully in several different clinical scenarios in infants and children including sedation during mechanical ventilation, procedural sedation, supplementation of postoperative analgesia, preven-tion of emergence delirium, control of post-anesthesia shivering, and the treatment of withdrawal.6 Several po-tential perioperative benefits of dexmedetomidine have been demonstrated including a decreased requirement for inhalational and intravenous anesthetic agents, blunting of the sympathetic stress response, decreased postoperative opioid requirements, and the prevention of postoperative shivering.6-8 The authors report the perioperative use of dexmedetomidine in a 28-year-old patient with Riley-Day syndrome. Previous reports of the perioperative use of dexmedetomidine in patients with FD are reviewed and its effects on the sympathet-ic nervous system discussed.

CASE REPORTInstitutional Review Board approval for case reports involving one or two patients is not required by Na-tionwide Children’s Hospital (Columbus, Ohio). The patient was a 28-year old, 22.5 kg female with a past medical history significant for Riley-Day syndrome, delayed psychomotor development, mental retarda-tion, unspecified osteoporosis, and severe gastric reflux. She had a long history of breath holding spells and self-mutilation behaviors. She appeared to be approximate-ly 7-8 years of age and was non-verbal. In May 2007 she had undergone a Nissen fundoplication with place-ment of a jejunostomy feeding tube to allow for enteral nutrition. A few months prior to this encounter, she was tolerating her feedings well through the gastros-tomy tube, which had been placed prior to the Nissen/jejunostomy tube in 2006. She no longer required the jejunostomy tube. Therefore, the decision was made in March of 2012 to close the jejunostomy as it resulted in severe irritation of her skin. After an uneventful stan-dard general anesthetic, the jejunostomy was closed and ultimately healed after a superficial wound infec-tion. In the ensuing months following this procedure, the patient had significant bloating with feedings and it was decided that the best course of management was replacement of the jejunostomy tube. A review of the patient’s previous anesthetics showed no prior expo-sure to dexmedetomidine and the clinicians used typi-cal opiate dosing for an opiate-tolerant patient. Her long history of agitation was treated on the inpatient

wards with nurse-controlled opiate analgesic strategies. On 7th postoperative day after the proximal gastroje-junostomy, an evisceration of the intra-abdominal con-tents was noted secondary to fascial dehiscence, neces-sitating a return to the operating room for exploratory laparotomy and wound closure. Preoperative medications included dicyclomine, ran-itidine, lansoprazole, inhaled budesonide and nystatin. The patient was held nil per os for 6 hours and was transported to the operating room where routine mon-itors were placed. Following pre-oxygenation, a modi-fied rapid sequence intubation using cricoid pressure was performed with the administration of propofol 3 mg/kg, fentanyl 2.5 μg/kg and rocuronium 0.8 mg/kg. Maintenance anesthesia consisted of desflurane with an exhaled concentration of 3-5% and morphine (0.1 mg/kg). Surgical exploration revealed that the fascia on the patient’s right side had failed. The remainder of the bowel was intact. The fascia was re-approximated and an nasogastric tube was placed in the gastric pouch. The surgical procedure lasted approximately 90 min-utes. Intraoperative fluids included 800 mL of lactated Ringer’s solution and 100 mL of normal saline. Follow-ing completion of the surgical procedure, residual neu-romuscular blockade was reversed with neostigmine, administered with glycopyrrolate, and the patient’s trachea was extubated. The patient was transported to the postoperative anesthesia care unit (PACU) where there were multiple episodes of breath holding result-ing in decrease of the oxygen saturation measured by pulse oximetry to 50% range. These breath holding spells were self-limited with the addition of facemask oxygen support but were accompanied by significant agitation. She appeared to be at her reported baseline and therefore no additional laboratory analysis was deemed warranted at that time. Along with these epi-sodes of oxygen desaturation, the patient had hyper-tension (144/91 mmHg), tachycardia (heart rate 140-160 beats/minute), diaphoresis and agitation. There was minimal change following the administration of hydromorphone (0.005mg/kg) and the initiation of a hydromophone-NCA (nurse controlled analgesia). A bolus dose of dexmedetomidine (0.4 μg/kg) was admin-istered which resulted in a decrease of her BP to 118/80 mmHg, cessation of the diaphoresis, control of agita-tion, and a decrease of the heart rate to 100-120 beats/minute. She maintained her oxygen saturations >95% with a nasal cannula at 2 L/min of oxygen flow with a respiratory rate of 20-24 breaths/min. The patient was admitted to the Pediatric ICU and a dexmedetomi-dine infusion at 0.3μg/kg/hr was started, in addition to the hydromorphone-NCA. The dexmedetomidine infusion was continued for 60 hours. There were no additional episodes of hypertension, tachycardia, and

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 85

case report

agitation; she was able to be easily weaned from dexme-detomidine at the conclusion of therapy. The remain-der of her postoperative course was unremarkable and she was discharged home on postoperative day 11.

DISCUSSIONIndividuals with FD present multiple intraoperative anesthetic challenges across many organ systems. Dys-autonomic crisis are a common perioperative problem manifested by vomiting, diaphoresis, hemodynamic lability, bradycardia, and tachycardia. These problems can be precipitated by emotional stress, anxiety and/or pain.3 Patients with FD have a reduction in the number of peripheral neurons in the sympathetic ganglia and a loss of sympathetic innervation of blood vessels.9,10 Orthostatic hypotension without reflex tachycardia is common in these patients and this abnormal baroreflex may be due to a dysfunctional parasympathetic system.11 Additional evidence for autonomic dysfunction is the presence of a prolonged QT interval in these patients.12 Issues related to increased sympathetic outflow in pa-tients with FD include hyperhidrosis which may result in perioperative hypovolemia and hyponatremia.13 As such, perioperative management and control of the la-bile autonomic system is of utmost importance.13,14 Historically, diazepam has been used to control the au-tonomic crises of FD while more recently clonidine, an α2-adrenergic, has been shown to be effective for refrac-tory cases especially those manifesting hypertension.13,14 Like clonidine, dexmedetomidine is in the imidazole subclass of the an α2-adrenergic agonists. The α2:α1 specificity of clonidine is 220:1, while that of dexme-detomidine is 1620:1, making dexmedetomidine a com-plete α2-agonist.15 Additionally, dexmedetomidine has a shorter half-life (2-3 hours) compared to clonidine (12-24 hours) and is available for intravenous administra-tion. Given its shorter half-life, it can be easily titrated by intravenous infusion while its effects dissipate more rapidly in the event of adverse effects. Additionally, there is significant experience with its perioperative use in infants and children.6,7

Centrally acting α2-adrenergic agonists reduce norepi-nephrine release through central effects on receptors in the medullary vasomotor center. Biochemical data from a cohort of 8 adult postoperative patients demon-strate the sympatholytic effects of dexmedetomidine.7 Following a 60 minute dexmedetomidine infusion to achieve a therapeutic plasma concentration of 600 pg/mL, the plasma norepinephrine concentration de-creased from 2.1 ± 0.8 to 0.7 ± 0.3 nmol/L, the plasma epinephrine concentration decreased from 0.7 ± 0.5 to 0.2 ± 0.2 nmol/L, HR decreased from 76 ± 15 to 64 ± 11 beats/min; and systolic BP decreased from 158 ±

23 to 140 ± 23 mmHg. The same investigators evalu-ated changes in plasma and urinary catecholamines in 41 adult patients undergoing vascular surgery.16 When compared to patients receiving dexmedetomidine, plas-ma norepinephrine concentrations were 2-3 times high-er at the time of tracheal extubation and at 60 minutes after arrival in the post-anesthesia care unit in the con-trol group. Urinary normetanephrine levels increased significantly in the placebo group, while no change was noted in patients receiving dexmedetomidine. A similar sympatholytic effect has been demonstrated following the intraoperative administration of dexmedetomidine to pediatric patients undergoing cardiopulmonary by-pass and surgery for congenital heart disease.17 Given that autonomic dysfunction with hyperactivity of the sympathetic nervous system may result in peri-operative problems in patients with FD, there is sound physiologic rationale for the use of an agent like dex-medetomidine that effectively blunts this response.18 Dexmedetomidine has been used effectively to control the sympathetic nervous system in other disorders of autonomic dysfunction including withdrawal from alcohol as well as iatrogenic opiate or benzodiazepine use.19-24 Anecdotal experience has also demonstrated the efficacy of dexmedetomidine to treat paroxysmal autonomic instability with dystonia (PAID). PAID, sometimes referred to as “sympathetic storms” or “dys-autonomia,” is most often seen in patients with trau-matic brain injury, tumor, and acute hydrocephalus.25 The tachycardia, hypertension, hyperprexia, tachype-nea, and diaphoresis seen in PAID patients may be due to a loss of inhibitory input to sympathetic feedback loops.24 Goddeau et al reported their experience with a 38-year-old patient suffering from PAID after traumat-ic brain injury, who did not respond to the standard treatment including morphine, fentanyl, labetalol, lorazepam, metoprolol and clonidine. Following the institution of a dexmedetomidine infusion which was titrated to 0.7 μg/kg/hr and continued for 72 hours, all other medications were able to be discontinued and the PAID was well controlled. There is additional anecdotal experience with the use of dexmedetomidine in patients with FD (Table 1).26-

28 These cases demonstrate the potential utility of us-ing dexmedetomidine as part of a balanced anesthetic technique during intraoperative care. In the first two cases, the dexmedetomidine was discontinued intra-operatively while Koshibe and Lee continued the infusion at a decreased dose of 0.2μg/kg/hr into the recovery phase until the PCA device was started. In our patient, a bolus dose of dexmedetomidine (0.4μg/kg) effectively controlled the postoperative hyperten-sion, tachycardia, and agitation. Our patient’s agitation and hemodynamic status was not affected by the use

86 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

dexmedetomidine in Riley-Day syndrome

of narcotics especially with the coexistent breath hold-ing spells. She responded well clinically in the immedi-ate postoperative period and into the next few days of dexmedetomidine therapy. She was easily weaned off dexmedetomidine therapy at the conclusion of her 60 hour course.In addition to controlling the sympathetic nervous system and potentially preventing the hemodynamic lability, that may occur in patients with FD, dexme-detomidine may also facilitate the emergence process by preventing emergence delirium, decreasing shiver-ing, and potentiationPACU = post-anesthesia care unit; BP = blood pres-sure; SNP = sodium nitroprusside

Table 1: Anecdotal experience with dexmedetomidine in patients with familial dysautonomia

Author and reference Patient demographics Dexmedetomidine dosing Description of outcome

Abulhasan Y et al.26 10-month-old girl for laparoscopic gastrostomy tube insertion.

Maintenance anesthesia included propofol (100-150 µg/kg/min) and dexmedetomidine administered as a bolus dose of 0.5 µg/kg followed by an infusion of 0.7 µg/kg/hr.

No hemodynamic changes during surgical manipulation. Infusions of propofol and dexmedetomidine discontinued at the completion of the surgical procedure. One episode of hypertension in the PACU related to pain. Resolved with morphine.

Gurbuxani G et al.27 16-year old male undergoing renal transplant surgery

Dexmedetomidine infusion was started at 0.1 µg/kg/hr along with remifentanil 0.05 µg/kg/min for arterial cannula placement. Following induction, dexmedetomidine was continued at 0.2-0.3 µg/kg/hr.

Transient decrease in BO after unclamping the IVC was treated by decreasing dexmedetomidine from 0.3 to 0.2 µg/kg/hr. During emergence, SNP required for BP control. The authors theorized that a large dose of dexmedetomidine may have prevented the BP increase during emergence.

Koshibe G and Lee HT.28 27-year old male undergoing renal transplant surgery

Dexmedetomidine infusion at 0.7 µg/kg/hr was started just prior to induction. Induction was intravenous with propofol and succinylcholine followed by midazolam and fentanyl after intubation.

Immediately after intubation the patient’s BP rose to 210/130 mmHg. Midazolam and additional divided doses of fentanyl were given with minimal BP change. Nitroprusside infusion (0.2 µg/kg/hr) was started and BP slowly decreased to 150s/100s mmHg. Dexmedetomidine infusion was continued during extubation to decrease stress and the possibility of triggering a dysautonomic crisis.

of the opioid analgesia.6,8,29 The opioid sparing effect of dexmedetomidine may be particularly important in pa-tients with FD. Axelrod et al noted the frequent need for postoperative ventilation with the use of opioids following abdominal surgery in patients with FD.30

CONCLUSIONDespite relatively limited anecdotal experience, the physiologic basis of FD and the pharmacologic mecha-nisms of dexmedetomidine provide a sound physiolog-ic rationale suggesting that it should be considered as a valuable agent in the perioperative management of familial dysautonomia (FD), also known as Riley-Day syndrome.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 87

case report

1. Riley CM, Day RL, Greeley DM, Langford WS. Central autonomic dysfunction with defective lacrimation: report of 5 cases. Pediatrics 1949;3:468-77. [Medline]

2. Slaugenhaupt SA, Blumenfeld A, Gill SP, Leyne M, Mull J, Cuajungco MP, et al. Tissue-specific expression of a splicing mutation in the IKBKAP gene causes familial dysautonomia. Am J Hum Genet 2001;68:598-605. [Medline]

3. Pearson J, Axelrod F, Dancis J. Current concepts of dysautonomia: neuropathological defects. Ann N Y Acad Sci 1974;228:288-300 [Medline]

4. Smith AA, Dancis J. Catecholamine release in familial dysautonomia. N Engl J Med 1967; 277:61-4. [Medline]

5. Bickel A, Axelrod FB, Schmelz M, Marthol H, Hilz MJ. Dermal microdialysis provides evidence for hypersensitivity to noradrenaline in patients with familial dysautonomia. J Neurol Neurosurg Psychiatry 2002;73:299-302. [Medline]

6. Tobias JD. Dexmedetomidine: Applications in pediatric critical care and pediatric anesthesiology. Pediatr Crit Care Med 2007;8:115-31. [Medline]

7. Talke P, Richardson CA, Scheinin M, Fisher DM. Postoperative pharmacokinetics and sympatholytic effects of dexmedetomidine. Anesth Analg 1997;85:1136-42. [Medline]

8. Tobias JD, Gupta P, Naguib A, Yates AR. Dexmedetomidine: applications for the pediatric patient with congenital heart disease. Pediatr Cardiol 2011;32:1075-87. [Medline]

9. Pearson J, Pytel BA, Grover-Johnson N, Axelrod FB, Dancis J. Quantitative studies of dorsal root ganglia and neuropathologic observations on spinal cords in familial dysautonomia. J Neurol Sci 1978;35:77-92. [Medline]

10. Grover-Johnson N, PearsonJ. Deficient vascular innervation in familial dysautonomia, an explanation for vasomotor instability. J Neuropathol Appl Neurobiol 1976;2:217-24.

DOI: 10.1111/j.1365-2990.1976.tb00498.x11. Stemper B, Bernardi L, Axelrod FB, Welsch

G, Passino C, Hilz MJ. Sympathetic and parasympathetic baroreflex dysfunction in familial dysautonomia. Neurology 2004; 63:1427-31. [Medline]

12. Glickstein JS, Schwartzman D, Friedman D, Rutkowski M, Axelrod FB. Abnormalities of the corrected QT interval in familial dysautonomia: an indicator of autonomic dysfunction. J Pediatr 1993; 122:925-28. [Medline]

13. Ngai J, Kreynin I, Kim JT, Axelrod FB. Anesthesia management of familial dysautonomia. Paediatr Anaesth 2006;16:611-20. [Medline]

14. Gold-von Simson G, Axelrod FB. Familial dysautonomia: update and recent advances. Curr Probl Pediatr Adolesc Health Care 2006; 36:218-37. [Medline]

15. Virtanen R, Savola JM, Saano V, Nyman L. Characterization of the selectivity, specificity and potency of medetomidine as an α2-adrenoceptor agonist. Eur J Pharmacol 1998;150:9-14. [Medline]

16. Talke P, Chen R, Thomas B, Aggarwall A, Gottlieb A, Thorborg P, et al. The hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery. Anesth Analg 2000;90:834-39. [Medline] [Free Full Article]

17. Mukhtar AM, Obayah EM, Hassona AM. The use of dexmedetomidine in pediatric cardiac surgery. Anesth Analg 2006;103:52-6. [Medline]

18. Maze M, Segal IS, Bloor BC. Clonidine and other alpha2 adrenergic agonists: strategies for the rational use of these novel anesthetic agents. J Clin Anesth 1998; 1:146-57. [Medline]

19. Riihioja P, Jaatinen P, Haapalinna, Kiianmaa K, Hervonen A. Effects of dexmedetomidine on rat locus ceruleus and ethanol withdrawal symptoms during intermittent ethanol exposure. Alcohol Clin Exp Res 1999;23:432-8. [Medline]

20. Riihioja P, Jaatinen P, Haapalinna, et al. Prevention of ethanol-induced sympathetic overactivity and degeneration by dexmedetomidine. Alcohol 1995;12:439-46. [Medline]

21. Maccioli GA. Dexmedetomidine to facilitate drug withdrawal. Anesthesiology 2003;98:575-7. [Medline]

22. Multz AS. Prolonged dexmedetomidine infusion as an adjunct in treating sedation-induced withdrawal. Anesth Analg 2003;96:1054-5. [Medline]

23. Baddigam K, Russo P, Russo J, Tobias JD. Dexmedetomidine in the treatment of withdrawal syndromes in cardiothoracic surgery patients. J Intensive Care Med 2005;20:118-23. [Medline]

24. Tobias JD. Dexmedetomidine to treat opioid withdrawal in infants and children following prolonged sedation in the Pediatric ICU. J Opioid Manag 2006;2:201-6. [Medline]

25. Goddeau RP, Silverman SB, Sims JR. Dexmedetomidine for the treatment of paroxysmal autonomic instability with dystonia. Neurocrit Care 2007;7:217-20. [Medline]

26. Abulhasan Y, Buu N, Frigon C. Perioperative use of dexmedetomidine in an infant with familial dysautonomia. Br J Anaesth 2009;103:413-5. [Medline] [Free Full Article]

27. Gurbuxani G, Neeta S, Lena S. Anesthetic management of a patient with familial dysautonomia for renal transplant surgery. Paediatr Anaesth 2008; 18:1271-2. [Medline]

28. Koshibe G, Lee HT. Anesthetic management of renal transplantation in a patient with familial dysautonomia. J Anesth 2009; 23:579-82. [Medline]

29. Easley RB, Brady KM, Tobias JD. Dexmedetomidine for the treatment of postanesthesia shivering in children. Paediatr Anaesth 2007;17:341-6. [Medline]

30. Axelrod FB, Donenfeld RF, Danziger F, Turndorf H. Anesthesia in familial dysautonomia. Anesthesiology 1988;68:631-5. [Medline] [Free Full Article]

REFERENCES

88 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

cAse RePoRT

successful treatment of severe Legionella pneumonia and acute kidney injury with polymyxin B-immobilized fiber column direct hemoperfusionYasunari Matsuki, MD*, Yuka Matsuki, MD**, Yoshikazu Yasuda, MD*, Maki Mizogami, MD**, Ko Takakura, MD**, Kenji Shigemi, MD**

*Department of Intensive Care Unit, **Department of Anesthesiology & Reanimatology, University of Fukui, Faculty of Medicine Sciences, Fukui (Japan)

Correspondence: Yasunari Matsuki, MD, Department of Intensive Care Unit, University of Fukui, Faculty of Medicine Sciences, 23-3 Shimoaizuki, Matsuoka, Eiheijicho, Yoshidagun, Fukui 910-1193 (Japan); Tel: +81-776-61-8391; Fax: +81-776-61-8116; E-mail: tainobu@u-fukui.ac.jp

ABSTRACTLegionella pneumonia is often complicated by multiple organ failure. Although acute kidney injury is relatively rare in the context of Legionella pneumonia, it is associated with an increase in mortality rate. This report describes a case of a patient with Legionella pneumonia and acute kidney injury who was successfully treated with polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP). We conclude that PMX-DHP may be a useful therapeutic modality in patients with Legionella infection and acute kidney injury.

Key words: Legionella pneumonia; Polymyxin B-immobilized fiber column direct hemoperfusion; Acute kidney injury

Citation: Matsuki Y, Matsuki Y, Yasuda Y, Mizogami M, Takakura K, Shigemi K. Successful treatment of severe Legionella pneumonia and acute kidney injury with polymyxin B-immobilized fiber column direct hemoperfusion. Anaesth Pain & Intensive Care 2013;17(1):88-90

INTRODUCTIONLegionella pneumonia was first described following an outbreak of pneumonia among army veterans attending an American Legion convention in Philadelphia in 1976.1 This pneumonia is often complicated by multiple organ failure, including acute kidney injury and hepatic dysfunction, that is associated with an increase in mortality rate.2-3 Polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is a useful treatment modality for patients with organ dysfunction due to severe sepsis.4 We describe a case of a patient with severe Legionella pneumonia and acute kidney injury who was successfully treated with PMX-DHP.

CASE REPORTA 70 years old man was admitted to our hospital with diarrhea, high-grade fever and dyspnea. He had been on treatment for malignant lymphoma, and had mitral valvuloplasty in the past. Physical examination on admission to our hospital revealed a temperature of 38.8°C, blood pressure of 65/40 mmHg, heart rate of 89/min, SpO2 of 80% (on 15 L/min of O2 via reservoir

mask) and a respiratory rate of 35/min. Glasgow coma scale was 9/15. Fine crackles were audible in the upper lung fields bilaterally. Laboratory tests showed elevations in leukocytes and C-reactive protein at 13,100/μl and 35.20 mg/100 ml respectively. BUN (28 mg/100 ml), Creatinine (1.64 mg/100 ml), AST (1019iu/L), ALT (677 iu/L) and LDH (1756 iu/L) were also elevated, and the Na level (127 mEq/L) was low. Arterial blood gas analysis (taken while O2 was being administered at 15 L/min via reservoir mask) showed severe hypoxemia, and metabolic acidosis (pH of 7.06, PaCO2 of 54 mmHg, PaO2 of 52 mmHg, HCO3

- of 14.5 mmol/L). Chest x-ray film showed infiltrative shadows in the left upper lung fields, and a chest CT revealed consolidation and ground-glass opacity in the left upper lung field (Fig 1-A&B).

The patient’s clinical course is summarized in Fig 2. He was admitted to the intensive care unit (ICU) with a blood pressure of 78/42 mmHg despite administration of 5 μg/kg/min of dopamine hydrochloride and 0.1 μg/kg/min of noradrenaline. He was immediately intubated and ventilated with 100% oxygen and was treated with sivelestat sodium hydrate, intravenous fluids of volume

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 89

case report

DISCUSSIONThe bacterium, Legionella, got its name after a 1976 outbreak, when many people who went to a Philadelphia convention of the American Legion suffered from this disease, a type of pneumonia (lung infection). Although this type of bacterium was around before 1976, more illness from Legionnaires’ disease is being detected now. The report describes the case of a patient with Legionella pneumonia and acute kidney injury who was successfully treated with PMX-DHP. Legionella pneumophila is one of the three most common causes of severe community-acquired acute pneumonia and comprises 3-6% of all cases of community-acquired pneumonias.5,6 Although radiologic and clinical findings alone are not sufficient to establish a diagnosis of Legionella pneumonia, if these are accompanied by diarrhea, neurological signs, a temperature >39°C, hyponatremia and hepatic dysfunction, these are strongly suggestive of legionellosis.7-9 Diarrhea, hyponatremia and hepatic dysfunction were noted in our present case. The patient was ultimately diagnosed with legionellosis on the basis of positive specific urinary antigen.Although Legionella pneumonia complicated by acute kidney injury is a rare disease, it is associated with a mortality rate greater than 50%.2,3 In our case, rhabdomyolysis was not observed, and we speculated that direct microbial toxicity,10 endotoxemia,

Fig 1-A: Chest radiograph on admission. There is an infiltrative shadow in the left upper lung field.

Fig 1-B: Chest computed tomography on admission showing consolidation with ground-glass opacities in the left lung field

PMX-DHP PMX-DHP

Fig 2: Clinical course after initiation of PMX-DHP. Catecholamines (noradrenaline and dopamine) were tapered off, and blood pressure and the PaO2/FiO2 (P/F) ratio gradually improved.(Legend: NA: noradrenaline, DOA: dopamine, CHDF: continuous hemodiafiltration, PMX-DHP: polymyxin B-immobilized fiber column direct hemoperfusion, sBP: systolic blood pressure, dBP: diastolic blood pressure)

and antibiotics (tazobactam/piperacillin, pazufloxacin). A diagnosis of legionellosis was made on the basis of positive specific urinary antigen. Antibiotics were switched to erythromycin, but blood pressure and the PaO2/FiO2 (P/F) ratio continued to decrease. He became anuric, and continuous hemodiafiltration (CHDF) (CH-1.0®; Toray Medical Co., Tokyo, Japan) was started to maintain body water balance. In addition, PMX-DHP (Toraymyxin 20R®; Toray Medical Co., Tokyo, Japan) was performed for 4 hours on days 1 and 2 to adsorb endotoxin. After the introduction of PMX-DHP, blood pressure and urinary output were gradually increased, and catecholamines were tapered off. The P/F ratio improved from 173 to 386 on day 3, and CHDF was terminated on day 8. The patient was extubated on day 9 after careful weaning from mechanical ventilation.

90 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

successful treatment of severe Legionella pneumonia and acute kidney injury

inflammatory cytokines11 and/or hypotension was the cause of acute kidney injury. L. pneumophila is a Gram-negative aerobic bacterium that is an intracellular parasite, and produces beta-lactamase and many other potential endotoxins.PMX-DHP can lower the plasma level of endotoxin and inflammatory cytokines,12,13 and can significantly improve hemodynamics and organ function in patients with severe sepsis and/or septic shock arising from Gram-negative bacterial infections.4,14 In the present case, early use of PMX-DHP resulted in improved

hemodynamics and kidney function. PMX-DHP exerts a therapeutic effect in patients with pneumonia by absorbing cytokines (e.g. IL-8) and neutrophil elastase produced by activated neutrophils PMX-DHP,15,16 and this was the likely mechanism of therapeutic action in our patient.

CONCLUSIONWe conclude that PMX-DHP may be a useful therapeutic modality in patients with Legionella infection and acute kidney injury.

1. Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG, et al. Legionnaires’ disease. Description of an epidemic of pneumonia. N Engl J Med. 1977;297(22):1189-97. [PubMed]

2. Harvey M, Quirke P, Warren D. Acute renal failure complicating Legionnaires’ disease. Postgrad Med J. 1980 Sep;56(659):672-4. [PubMed] [Free full article]

3. Lin SL, Chen HS, Yu CJ, Yen TS. Legionnaires’ disease with acute renal failure: report of two cases. J Formos Med Assoc. 1995 Mar;94(3):123-6. [PubMed]

4. Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009 Jun 17;301(23):2445-52. doi: 10.1001/jama.2009.856. [PubMed] [Free full article]

5. Mundy LM, Auwaerter PG, Oldach D, Warner ML, Burton A, Vance E, et al. Community-acquired pneumonia: impact of immune status. Am J Respir Crit Care Med. 1995 Oct;152(4 Pt 1):1309-15. [PubMed]

6. Marston BJ, Plouffe JF, File TM Jr, Hackman BA, Salstrom SJ, Lipman HB, et al. Incidence of community-acquired pneumonia requiring

hospitalization. Results of a population-based active surveillance Study in Ohio. The Community-Based Pneumonia Incidence Study Group. Arch Intern Med. 1997 Aug 11-25;157(15):1709-18. [PubMed]

7. Stout JE, Yu VL. Legionellosis. N Engl J Med. 1997 Sep 4;337(10):682-7. [PubMed]

8. Katz DS, Leung AN. Radiology of pneumonia. Clin Chest Med. 1999 Sep;20(3):549-62. [PubMed]

9. Mulazimoglu L, Yu VL. Can Legionnaires disease be diagnosed by clinical criteria? A critical review. Chest. 2001 Oct;120(4):1049-53. [PubMed]

10. Wong KH, Moss CW, Hochstein DH, Arko RJ, Schalla WO. “Endotoxicity” of the Legionnaires’ disease bacterium. Ann Intern Med 1979; 90: 624-627. [PubMed]

11. Remick DG, Kunkel SL. Toxic effects of cytokines in vivo. Lab Invest. 1989 Mar;60(3):317-9. [PubMed]

12. Kushi H, Miki T, Okamaoto K, Nakahara J, Saito T, Tanjoh K. Early hemoperfusion with an immobilized polymyxin B fiber column eliminates humoral mediators and improves pulmonary oxygenation. Crit Care 2005; 9: 653-661. [PubMed] [Free full article]

13. Seo Y, Abe S, Kurahara M, Okada D, Saito

Y, Usuki J, et al. Beneficial effect of polymyxin B-immobilized fiber column (PMX) hemoperfusion treatment on acute exacerbation of idiopathic pulmonary fibrosis. Intern Med. 2006;45(18):1033-8. Epub 2006 Oct 16. [PubMed] [Free full article]

14. Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009 ;301:2445-2452. [PubMed] [Free full article]

15. Abe S, Seo Y, Hayashi H. Neutrophil adsorption by polymyxin B-immobilized fiber column(PMX) for acute exacerbation in patients with interstitial pneumonia: a pilot study. Blood Purif. 2010;29(4):321-6. doi: 10.1159/000287232. Epub 2010 Feb 24. [PubMed] [Free full article]

16. Kawagishi N, Ohkohchi N, Fujimori K, Orii T, Koyamada N, Kikuchi H, Satomi S. The effect of continuous veno-venous hemofiltration or direct hemoperfusion with polymyxin B-immobilized fiber on neutrophil respiratory oxidative burst in patients with sepsis and septic shock. Ther Apher. 2001 Feb;5(1):7-11. [PubMed]

REFERENCES

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 91

cAse RePoRT

Accidental asphyxiation by an Arabic headscarfSaid D. Abuhasna, MD*, Mustafa Abu Ebaid, MD**, Eman D.M. Qadoom, Pharm D***, Masood Ur Rahman, MD****

*Chairman; **** Deputy Chairman, Department of Critical Care Medicine**Resident, Department of Internal Medicine*** Department of Pharmacy

Tawam Hospital, P.O.Box 15258 Al Ain (United Arab Emirates)

Correspondence: Said Abuhasna, MD., Chairman, Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Abu Dhabi, (UAE); Email: sabuhasna@tawamhospital.ae ; sabuhasna@gmail.com

ABSTRACTSelf-strangulation is an important cause of homicidal and suicidal injury, leading to death due to asphyxia and may be accidental or suicidal. Accidental strangulation is rare, and to be strangulated by a scarf is even less common. We report a 19-year-old male who was accidentally strangulated by his own scarf or ‘ghutra’ (a traditional cotton headdress worn by Arab males), while working on his idle vehicle engine, resulting in anoxic brain encephalopathy. The patient remained in a persistent vegetative state and ventilator dependent.

Because this was previously an unrecognized hazard of ‘ghutra’ as well as the unique mode of injury, it prompted us to report this case to highlight the circumstances surrounding the event in order to minimize similar.

Key words: Headscarf; Ghutra; Strangulation; Anoxic brain encephalopathy

Citation: Abuhasna SD, Ebaid MA, Qadoom EDM, Rahman MU. Accidental asphyxiation by an Arabic headscarf. Anaesth Pain & Intensive Care 2013;17(1):91-93

INTRODUCTIONAccidental strangulation is rare, and to be strangulated by a scarf is even less common. The traditional Arabic headdress goes by several names. It is called a ‘keffiyeh’, ‘shmagh’, ‘ghutra’ or a scarf. It can be worn in several different ways, either by itself or with a cap (‘igal’) and wreath (‘tagiyyah’) to keep it in place. The scarf was initially used by the dwellers of the desert to protect them from the harsh rays of the sun and the whipping sands of the desert. It still serves that purpose, but now it has become a symbol of Arab culture. It is also worn at weddings and by heads of state, when it serves a purely decorative function. The ‘shmargh’ is a large square piece of cotton cloth that is woven in a distinctive checkered design. It is usually red and white, or black and white.1

We present a case of a 19 years old male who was accidentally strangled by his own scarf, while he was working on his idle running vehicle. The scarf was accidentally tangled into the fan of the engine and tightened around his neck leading to asphyxiation

and brain death, which left the patient in a persistent vegetative state.

CASE REPORTA 19 years old healthy male (weight 66 kg, height 155 cm) was admitted to our intensive care unit (ICU), comatosed with multiple facial abrasions and a fresh injury mark around his neck. The history was provided by the front seat passenger who was patient’s first cousin. The patient and his cousin were driving to report as newly inducted recruits to the police academy for training on a chilly morning. The patient was wearing the traditional scarf around his head and neck to keep him warm. On their way to the academy, the vehicle engine stalled. The patient reportedly exited the vehicle and opened the hood to check the engine. He was able to restart the engine while his head was still under the hood. Evidently, the fan of the engine started abruptly, catching his scarf in the fan belt, and tightening it progressively more and more around his neck leading to asphyxiation with loss of consciousness.

92 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

accidental asphyxiation by an Arabic headscarf

The passenger, who saw that his cousin head slammed on the engine, immediately turned off the engine and called Emergency Medical Service 911. Subsequently, he attempted to untangle the scarf and get it released from the fan, but he was not successful. The victim sustained asphyxiation and quickly became unconscious. The Emergency Medical Service transported the patient to the hospital on oxygen supplementation and monitoring. He was resuscitated at the trauma centre. Upon arrival to the ICU the patient was on a ventilator and was flaccid with a Glasgow coma scale of 3/15 and with decerebrate posture. The oxyhemoglobin saturation was 97% on FiO2 45%. The ventilatory rate was 12 in the assist control mode with a tidal volume of 6 ml/kg and a positive end-expiratory pressure (PEEP)

of 5 cmH2O. The heart rate was 75 bpm in normal sinus rhythm, the temperture was 37.1° C and the BP was 100/58 mmHg. The pupils were fixed and dilated at 7 mm. There was a ligature mark over the anterior neck (Figure 1). No other injuries were found. Rest of his examination was unremarkable.

In the subsequent few days, he suffered from episodes of generalized tonic-clonic convulsions and ARDS, probably due to aspiration pneumonia. Arterial blood gas analysis showed PO2 of 56 mmHg on FiO2 90% and the chest radiograph showed bilateral infiltrates. The plain radiograph of the neck did not reveal any hyoid or cervical vertebral fractures and a computerized tomography (CT) scan of cranium showed skull fracture with moderate subdural hematoma on the right parietal area which was surgically evacuated. CT scan of the neck was unremarkable. Patient was treated with intravenous phenytoin for seizures; on 5th day of ICU admission, he developed diabetes insipidus (DI) and was treated with desmopressin infusion. Due to his deep coma and vegetative state, tracheostomy was performed and he was placed on long term ventilation.

In different types of strangulation, the initially applied

ligature causes venous congestion with stasis of cerebral blood leading to unconsciousness. After the person is limp, the ligature can tighten, progressing to complete arterial occlusion. Vagal reflexes from pressure on the carotid bodies can lead to dysrhythmias. Airway compression does not play an important role in the pathophysiology of strangulation injuries. Laryngeal fractures have been reported in hanging deaths but are rare in survivors.

The clinical features of strangulation can include indentation of the neck in the course of the ligature or other signs of trauma to the neck, such as scratches, abrasions or lacerated wounds (Figure 1). Tardieu spots are petechial hemorrhages in the conjunctiva, mucous membranes, and skin cephalad to the ligature marks.2,3 Strangulation is a common method of homicide, but accidental ones like our case are rare. Accidental strangulation is a potentially fatal injury and only two cases similar to ours have been reported.4 In strangulation, and in some suicidal hangings where the individual is “saved” before death, there may be a variable period of survival, but with brain damage, followed by death. This delay is the effect of loss of blood flow to the brain, with partial asphyxiation of the brain. A decrease in blood flow to the brain will produce a pathologic change called anoxic encephalopathy. In our case there was strangulation with the headscarf, that resulted in anoxic encephalopathy and a vegetative state. The process of strangulation, whether by hand (manual) or by a ligature, results in blunt injury of the soft tissues of the neck. The pattern of these injuries allows us to recognize strangulation as a mechanism, and to distinguish strangulation from other blunt injuries including hanging, traumatic blows to the neck, and artifacts of decomposition.2,3 Fatal anoxic encephalopathy results in clinical “brain death” where the body functions of the heart and internal organs can be maintained by medical life support, but all hope of meaningful recovery is lost. Complications may include persistent vegetative coma, cerebral edema, and herniation of the brain. Apparently this is not the first case to die from strangulation of own headscarf. Searching the internet, we found two cases only reported in the news and information sites, but not in medical literature. The first case was of a well known American dancer named Angela Isadora Duncan, who died in a car accident in 1931. Her silk scarf, draped around her neck, became entangled around the open-spoked wheels and rear axle, breaking her neck.4 The second case was of a teenager girl Suzanne Cornwell, 18. She was strangled to death by her scarf in a freak go-karting accident when the garment got caught in the engine the first time she had ever tried the sport.

Figure 1. Ligature mark over the anterior neck.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 93

case report

Accidental strangulation of this variety is under-reported in the third world countries and is preventable if the public follows safety recommendations. Since the occurrence of this case we have started short courses of instructions to primary care physicians to provide

anticipatory guidance to the public of the United Arab Emirates, and to explain to their patients and their families the dangers and the potential strangulation by a headscarf in certain situations such as inspection of a vehicle under the hood while the engine is running.

1. How to Wear an Arabic Headdress: Available on http://www.ehow.com/how_6046805_wear-arabic-headdress.html. (Accessed on 10 March 2013).

2. Kelly M: Trauma to the neck and larynx

[Review]. CRNA 1997 Feb;8(1):22-30. [PubMed]

3. Missliwetz J, Vycudilik W: Homicide by strangling or dumping with postmortem injuries after heroin poisoning? Am J Forensic

Med Pathol. 1997 Jun;18(2):211-4. [PubMed]

4. Craine, Debra and Mackrell J. The Oxford Dictionary of Dance. Oxford University Press, Oxford. 2000; p152. ISBN 0-19-860106-9

REFERENCES

94 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

cAse RePoRT

Failed ventilation with LMA Proseal® in a patient with sleep apnea syndromeAnju Ghai, MD*, Sarla Hooda, DA, MD*, Raman Wadhera, MS**, Nandita Kad, DA, DNB*, Nidhi Garg, MD***

*Professor of Anesthesiology; ***P.G. StudentDepartment of Anesthesiology and Critical Care

**Professor of ENTDepartment of Ear, Nose & Throat

Pt. B.D. Sharma PGIMS, Rohtak, Haryana (India) 124001

Correspondence: Dr. Anju Ghai, 19/9 J, Medical Enclave, Pt. B.D. Sharma, PGIMS, Rohtak (India); E-mail: dr.wadhera@yahoo.com

ABSTRACTPatients with sleep apnea syndrome (SAS) have excessive adipose tissue in oropharynx which can obstruct the airway. A high prevalence of difficult intubation has been reported in these patients and an association between the severity of SAS and difficult intubation has been suggested. LMA Proseal® (LMA Company, USA) has been launched as a better alternative to LMA classic, as it provides good airway seal due to its modified cuff. The improved seal of LMA Proseal® (PLMA®) has an advantage in obese patients where higher airway pressures are required for positive pressure ventilation. We found that LMA Classic® provided better airway management than PLMA® in one of our obese patients with SAS.

Key Words: LMA Proseal® (PLMA®); LMA Classic®; Sleep apnea syndrome; Positive pressure ventilation; Supraglottic device

Citation: Ghai A, Hooda S, Wadhera R, Kad N, Garg N.Failed ventilation with LMA Proseal® in a patient with sleep apnea syndrome. Anaesth Pain & Intensive Care 2013;17(1):94-96

INTRODUCTIONObstructive sleep apnea is a syndrome, characterised by partial or complete obstruction of the upper airway during sleep due to inadequate pharyngeal muscle tone. These patients may have a compromised airway due to oropharyngeal narrowing as there is deposition of fat in collapsible segments of the airway.1 SAS severity is measured by the apnea hypoapnea index (AHI) which is defined as number of apnea / hypoapnea events per hour of sleep and the lowest oxygen saturation associated with an abnormal respiratory events during sleep. Theoretically, the larger the pharyngeal tissue, the higher the AHI will be. Patients with SAS have many implications for anesthesia. These patients usually pose a problem of difficult intubation as they have abnormal facial and upper airway morphology, e.g. retrognathia, short and thick neck and a large tongue.2 Hiremath et al found a high prevalence of SAS in patients with difficult intubation retrospectively.3 Sleep apnea results in fragmented sleep, hypoxemia, day time somnolence

and altered cardiopulmonary functions.

PLMA® is a modification of classic® LMA. It has a larger and deeper bowl with no grille and cuff extends posteriorly to give a more effective seal around the glottis. It has a drainage tube running parallel to the airway tube which provides a bypass channel for regurgitated gastric contents and allows rapid diagnosis of mask misplacement. Since the airway tube of PLMA® is shorter than LMA Classic® and of similar calibre, airway resistance is 20% more than LMA Classic®. The PLMA® is superior to LMA Classic® for providing positive pressure ventilation and at a given cuff pressure, provides twice the seal pressure of the LMA Classic®. The improved seal is of advantage in obese patients where higher airway pressure are required for positive pressure ventilation.4

A patient of obstructive sleep apnea is reported where PLMA® failed to provide adequate airway approach as compared to conventional LMA Classic®.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 95

case report

CASE REPORTA 51 year old male, weighing 90 kg, ASA grade II, with the diagnosis of gall stones and paraumbilical hernia was posted for cholecystectomy. He was a known case of SAS for 2 years. He also suffered from hypertension for two months and was on tab atenolol 50 mg and tab amlodipine 5 mg. His ECG showed ST segment flattening with T-wave inversion in V2-V5 leads. Chest x-ray revealed cardiomegaly. On general physical examination, he was found to have a short thick neck with a pulse rate of 80/min and B.P. 130/80 mmHg. Echocardiography revealed concentric left ventricular hypertrophy with ejection fraction of 54%. Symptoms of SAS were relieved with exercise and weight reduction. Pulmonary function tests revealed FEV1 3.5 L, FVC 4.04L, FEV1/FVC 86%, PEFR 297L/min and oxygen saturation 93% on room air. Polysomnographic studies revealed moderate apnea / hypoapnea episodes. A high risk informed consent was obtained. Antihypertensive drugs were ordered to be continued but no sedative drugs.

Standard monitoring e.g. electrocardiography, SpO2 and non-invasive blood pressure, was applied. Preoxygenation was carried out with 100% oxygen for 6 minutes. Routine induction protocol was followed. Direct laryngoscopy revealed Cormack and Lehane grade 4 view. Intubation could not be achieved despite two attempts. Fibroptic bronchoscope was not available to help intubation. Further attempts on intubation were abandoned to avoid airway trauma and sympathetic stimulation leading to surges in blood pressure in this patient. PLMA® size 4 was inserted and correct placement was confirmed by gentle inflation. An orogastric tube could be passed through the drain tube and a drop of gel placed over the proximal end of drain tube ruled out mask malposition. Airway pressures and end tidal CO2 were within normal limits. The surgery was started. Patient was ventilated by IPPV.

After about five minutes of placement, an increased resistance to ventilation was felt. Patient could not be ventilated adequately. EtCO2 rose to 60-70 mmHg. Airway pressure increased to 40 cmH2O. We considered it to be suboptimal positioning or an inappropriate size. An attempt at repositioning did not succeed in lowering the airway resistance. We replaced PLMA® size 4 with size 5. Gas leakage and resistance to ventilation was still noted. It was then replaced with LMA Classic® size 4. Fibroptic assessment could have been helpful, but it was not available. To our relief, the patient could now be ventilated adequately. Airway pressure dropped down and end tidal CO2 also lowered

down to 40 mmHg. Rest of intraoperative period was uneventful. Surgery lasted for one hour. At the end of surgery, when patient was fully awake, LMA was taken out. Nasopharyngeal airway was placed for 24 hours postoperatively so as to avoid obstruction.

DISCUSSIONControlled ventilation with tracheal intubation is the choice if general anesthesia with relaxation is the only available option. Nasal continuous positive airway pressure may be applied if airway obstruction persists, and it should be started before surgery and resumed immediately after extubation in cases of SAS.5

The cause of increased resistance to ventilation in our patient could be malpositioning, infolding of epiglottis or improper size. PLMA® provides more effective seal than LMA Classic® at same airway pressure4 due to the broader proximal cuff plugging the oropharynx more effectively and also the ventral cuff pressing the dorsal cuff firmly into periglottic tissues.6-8

The difficulty in ventilation with PLMA® in our case could be explained due to epiglottis impinging in the lumen of the airway tube during insertion causing obstruction. This is not seen with LMA Classic® as it has aperture bars. Though downfolded epiglottis does not impede airflow with PLMA® due to presence of accessory vent, but in this case impediment could be significant due to excessive perilaryngeal tissues. In addition any supraglottic airway device (SGD) with a large inflatable hypopharyngeal component can cause mechanical airway obstruction by vocal cord closure secondary to glottic compression.8

Stacy et al have reported 20% incidence of airway obstruction with these airway management devices. They hypothesized epiglottic downfolding or mechanical cord closure.9 In its resting state, the hypopharynx is usually closed. Any device occupying the hypopharynx sufficiently to form a seal must open it and push the glottis anteriorly. This will inevitably cause glottic compression in patients with unfavourable anatomy. The incidence of mechanical cord closure is 0.4%.10 Over-enthusiastic insertion and inflation of the PLMA® cuff beyond its optimal position results in near complete airway obstruction, presumably because of forward displacement of the glottic inlet. Application of cricoid pressure with the LMA Classic® may also simulate the same condition.11 Another cause of impaired ventilation could be infolding of the aryepiglottic folds.12 We could not perform a fiberoptic assessment, though it would have provided important clues about the etiology of the obstruction. It is strongly

96 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

failed ventilation with LMA Proseal®

1. Jonathan L. Benumof. Obesity, sleep apnea, the airway and anesthesia. Curr Opin Anaesthesiol. 2004 Feb;17(1):21-30. [Medline]

2. Siyam M.A., Benhamou D. Difficult Endotracheal Intubation in patients with Sleep Apnea Syndrome. Anaesth Analg 2002;95:1098-102. [Medline]

3. Hiremath AS, Hillman DR, James AL et al. Relationship between different tracheal intubation and obstructive sleep apnea. Br J Anaesthesia 1998;80:606-11. [Medline]

4. Keller C, Brimacombe J. Mucosal pressure and oropharyngeal leak pressure with the Proseal versus the Classic laryngeal mask airway in anaesthetized paralysed patients. Br

J Anaesth 2000;85:262-6. [Medline]5. Anaesthesia and sleep apnea. Br J Anaesth

2001;86(2):254-66. [Medline]6. Brain AIJ, Verghese C, Strube PJ. The LMA

‘Proseal’- a laryngeal mask with an oesophageal vent. Br J Anaesth 2000;84:650-4 [Medline]

7. Brimacombe J, Keller C. The Proseal laryngeal mask airway: Randomised crossover study with the standard laryngeal mask airway in paralyzed, anaesthetised patients. Anesthesiology 2000;93:104-9 [Medline]

8. Yanagimoto M: Effect of position of the epiglottis on volume-pressure curve during use of the LMA. J Jpn Soc Clin Anesth 1992;12:738-41 [Medline]

9. Stacey MR, Sivasankar R, Bahlmann UB,

Hughes RC, Hall JE. Mechanical closure of the vocal cords with the airway management device. Br J Anaesth 2003;91:299-03 [Medline]

10. Brimacombe J, Richardson C, Keller C, Donald S. Mechanical closure of the vocal cords with Proseal laryngeal mask airway. Br J Anaesth 2002;89:296-7 [Medline]

11. Brimacombe J, Berry A. Mechanical airway obstruction following cricoid pressure with the laryngeal mask airway. Anaesth Analg 2001;78:604-5 [Medline]

12, Dubreuil M, Janvier G, Dugrais G, Berthoud MC. Uncommon laryngeal mask obstruction. Can J Anaesth 1992;39:517-8 [Medline]

REFERENCES

recommended in the assessment of airway obstruction with SGD’s whenever clinical circumstances allow. The best options in case of inadequate ventilation after insertion of a SGD are to remove and reinsert it, or to opt for a different size. We exercised both of these options but failed. However, the change of SGD (LMA Classic® for PLMA®) resulted in successful ventilation.

Sedation and narcotic based analgesia was avoided in postoperative period in our patient as it could

exacerbate symptoms of sleep apnea. NSAID’s and local infiltration at incision site is preferred.

CONCLUSION

PLMA® has specially developed to improve the seal and ensure effective ventilation, but in our patient with SAS, it failed in its stated purpose. The cause of its failure cannot be ascertained with certainty. In case of failure, either the size or type of the SGD should be changed.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 97

cAse RePoRT

Airway management in a patient with a large mass in scapular region: A case reportHaidar Abbas, MD*, Zia Arshad MD**, Sulekha Saxena***, Jai Shree Bogra****

*Associate Professor; **Lecturer; ***MD Student; ****Professor & Head Department of Anesthesiology, King George’s Medical University, Chowk, Lucknow U.P. (India).

Correspondence: Dr. Sulekha Saxena, MD Student, Department of Anesthesiology, King George’s Medical University, Chowk, Lucknow U.P. (India); Cell: 09359618480; E-mail: dr.sulekha2008@rediffmail.com

ABSTRACT

Airway management is one of the most important routine tasks performed by an anesthesiologist. Adept airway management is an essential skill for an anesthesiologist. Although practice guidelines and algorithms may help in such situations, but vigilance and a timely decision remain all important in such a situation. We encountered a patient with a rapidly enlarging subscapular mass due to which maintenance of supine position on the operating table for laryngoscopy and intubation was almost impossible. We had little options for airway management during general anesthesia in this patient. We present our method of successful management in this case and reiterate the role of different methods of correct positioning and intubation in such circumstances.

Key words: Airway management; Laryngoscopy; Difficult airway; Fibreoptic intubation; LMA

Citation: Abbas H, Arshad Z, Saxena S, Bogra JS. Airway management in a patient with a large mass in scapular region: A case report. Anaesth Pain & Intensive Care 2013;17(1):97-99

INTRODUCTIONManagement of the difficult airway presents a great challenge for the anesthesiologist. Practice guidelines and algorithms are useful in such circumstances. However, the anesthesiologist’s judgment and vigilance remain the primary means to save airway management. There are few options for securing the airway during induction of general anesthesia in supine position, in a patient with a large mass on the back, which can be enumerated as follows. Placement of a proper wedge on the opposite side of the tumor to make the patient level in supine position without putting weight on the mass or to intubate patient in a lateral position may require some experience and skill. Fibreoptic intubation is the other option available but it is not usually available in the hospitals of the third world countries. We present here a case of large mass in scapular region which posed anticipated difficulty in maintaining supine position for intubation. The authors tried an alternate scheme to intubate this patient. Patient was taken on the edge of the table with the mass hanging between the edge of the table and the arm rest. By this way we were able to maintain the desired position for laryngoscopy and intubation and the airway was

managed successfully.

CASE REPORTA 55 yr old male presented with a large mass in scapular region posted for wide local excision and split thickness grafting in the Department of Surgery, King George’s Medical University Hospital, Chowk, Lucknow (Figures 1-A & 1-B). Patient was declared physically fit and ASA grade-1 on preanesthetic checkup. He had a short receding jaw and loose upper incisors, hence was anticipated to be a candidate for difficult laryngoscopy and intubation. Written consent was obtained and standard monitoring devices e.g. electrocardiogram, pulse oximetry, noninvasive blood pressure, and end-tidal carbon dioxide monitors, were attached to the patient in the operating room in the sitting position. An intravenous line with 18G cannula was passed. The mass was assessed and it was felt that the supine position would be difficult to obtain by using large cushions and pillows. The lateral position was an option but intubation in this position was felt to be particularly difficult in view of his short receding jaw and loose upper incisors. Due to same reasons LMA

98 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

airway management in a patient with a large mass in scapular region

insertion was also felt to be difficult in the lateral position. We placed the patient in the lateral position, facing towards opposite direction to his mass, on the extreme edge of the table. An arm rest was attached at the most cephaled end of the operating table. Then the patient was asked to roll over to a supine position so that the mass was hanging between the edge of the table and the arm rest (Figure 2). The right arm was supported over his chest and an assistant held the patient in position. Patient was given inj. glycopyrrolate 0.2 mg, inj. fentanyl 100mcg and inj. midazolam 1 mg IV. Anesthesia was induced with inj. propofol 120 mg and intubation was facilitated with inj succinyl choline 100 mg. Laryngoscopy was performed and endotracheal tube size 8.5 mm was placed successfully and secured. The patient was then paralyzed with inj. tracrium, ventilated and placed in lateral position for the surgery. He was extubated uneventfully at the end of the surgery in the lateral position.

DISCUSSIONAwake fibreoptic intubation remains the gold standard for anticipated difficult intubation.1 Blind nasal or oral intubation is a simple technique, but it is associated with two major drawbacks: infrequent success on the first pass, and increased trauma with repeated attempts. We could not risk precipitating complete airway obstruction that necessitated emergent cricothyrotomy.2-6 Also, insertion of the endotracheal tube via the nasal passage has a risk of nasal bleeding. This can result in an inability to visualize subsequent fibreoptic attempts due to both tissue edema and bleeding. Previous studies indicated fibreoptic nasotracheal intubations is associated with frequent failure (66% in some studies).6 However, there are reports of a greater success rate with this procedure, attributed to a well-organized approach, and expertise in flexible bronchoscopy.1,6 Unluckily, this procedure demands high level of expertise and skill for its success. The fiberscopes may not be available at all centers. Sitting fiberoptic bronchoscopic intubation can be life-saving, therefore, we suggest that anesthesiologists occasionally practice this technique so that it may be used when confronted with a patient requiring awake urgent intubation who cannot tolerate the supine position.Elective tracheostomy using local anesthesia has been considered the ‘definitive’ modality of airway management in difficult situations such as deep neck infections6–8. Nevertheless, it may be difficult or impossible in advanced cases such as in our case because of the supine position needed for tracheostomy, or due to the anatomical distortion of the anterior neck. In our case, surgeons were reluctant to perform tracheostomy using local anesthesia without a secure airway1,5,8.

Figure 1-B: The lateral patient position on the edge of the table, before placing him supine

Figure 2: Patient on the edge of the table with mass hanging between the edge of the table and the arm rest

Figure 1-A: Large mass in right scapular region

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 99

case report

Intubation in lateral position is requires experience and skill. In our case, we felt it particularly difficult due to features of difficult airway present in this patient. Due to same reasons, the use of LMA or i-gel was thought to be impractical.9,10

1. Ovassapian A. Fiberoptic Endoscopy and the Difficult Airway. 2nd ed. Philadelphia: Lippincott-Raven Press, 1996

2. Belmont MJ, Wax MK, DeSouza FN. The difficult airway: cardiopulmonary bypass—the ultimate solution. Head Neck 1998;20:266–9 [Medline]

3. Hariprasad M, Smurthwaite GJ. Management of a known difficult airway in a morbidly obese patient with gross supraglottic oedema secondary to thyroid disease. Br J Anaesth 2002;89:927–30 [Medline] [Free Full Article] doi: 10.1093/bja/aef274

4. Huitink JM, Balm AJ, Keijzer C, Buitelaar DR.

Awake fibrecapnic intubation in head and neck cancer patients with difficult airways: new findings and refinements to the technique. Anaesthesia 2007;62:214–9 [Medline]

5. Oka Y, Nishijima J, Azuma T, Inada K, Miyazaki S, Nakano H, et al. Blunt thyroid trauma with acute hemorrhage and respiratory distress. J Emerg Med 2007;32:381–5 [Medline]

6. Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg 2005;100:585–9 [Medline] [Free Full Article]

7. Tsilchorozidou T, Vagropoulos I, Karagianidou

C, Grigoriadis N. Huge intrathyroidal hematoma causing airway obstruction: a multidisciplinary challenge. Thyroid 2006;16:795–9 [Medline]

8. Heidegger T, Gerig HJ. Algorithms for management of the difficult airway. Curr Opin Anaesthesiol 2004;17:483–4 [Medline]

9. Ramachandran K, Kannan S. Laryngeal mask airway and the difficult airway. Curr Opin Anaesthesiol. 2004 Dec;17(6):491-3.

10. Drolet P. Management of the anticipated difficult airway--a systematic approach: continuing Professional Development. Can J Anaesth. 2009 Sep;56(9):683-701. doi: 10.1007/s12630-009-9144-4. Epub 2009 Jul 28.

REFERENCES

We performed the laryngoscopy and intubation in the usual way, except that the position of the patient was adjusted according to the mass on the back to make patient supine to maintain suitable position for laryngoscopy and intubation.

APICARE added to the Directory of Open Access Journals

“Anaesthesia, Pain & Intensive Care” has now been added to the Directory of Open Access Journals; have a look at the description at:http://www.doaj.org/openurl?genre=journal&issn=16078322

Benefits of supplying DOAJ with metadata:* Journals with the content in PDF format will be included in long term preservation project.* Statistics show more than 6 millions successful requests a month for DOAJ site from all over the

world.* Many web crawlers are fetching the content of DOAJ to be a part of their search engines.* DOAJ is OAI compliant. * Once the article is available in DOAJ, it becomes automatically OAI harvestable.* Many aggregators and database providers are regularly harvesting DOAJ content in order to include it

to their commercial databases.

100 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

LeTTeRs To eDIToR

Valsalva maneuver aids blind central venous catheterization Sukhen Samanta, MD* and Rudrashish Haldar, MD, PDCC**

*Department of Critical Care Medicine, **Department of Anesthesiology Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, 226014

Correspondence: Dr. Rudrashish Haldar, Old PG Hostel, Room No. 2, SGPGI, Lucknow, India, 226014; Email: rudrashish@yahoo.com; Mobile: 08004904625

Citation: Samanta S, Haldar R. Valsalva maneuver aids blind central venous catheterization. Anaesth Pain & Intensive Care 2013;17(1):100-101

To the Editor,Central venous catheterization (CVC) is routinely being practised in wards and emergency departments for central venous pressure monitoring, administration of ionotropes, hyperosmolar drugs, parenteral nutrition and chemotherapy. Ultrasonographic (USG) guidance and therapeutic beds for achieving Trendelenburg position provide valuable help in vessel access and performing this procedure safely. But at many locations and institutions these facilities may not be available, and use of the blind technique in supine position becomes mandatory. Blind technique is associated with significantly higher complication rate and a lower success rate. On the basis of normal human physiology, we opine that in such situations, the use of Valsalva maneuver (VM) to aid CVC increases the success rate. We illustrate this by two cases, where expected difficult CVC was simplified using VM.Case 1: A 15 years old male, diagnosed with aplastic anemia, required CVC for antithymocyte globulin administration. He had a cyst on left side of the neck and right sided skin excoriation due to a previously placed CVC in the right internal jugular vein (IJV). A platelet count of 20,000/mm3 in the patient prevented us from trying the blind subclavian approach. IJV cannulation on the right side was not attempted due to previous scar. USG machine and therapeutic bed were not available. After aseptic preparation and local anesthetic infiltration, the patient was asked to perform VM which made the external jugular vein (EJV) prominent. While the patient maintained VM, the EJV was punctured and the guidewire was threaded effortlessly through the EJV. A repeat VM helped guide the CVC over the guidewire. Case 2: A 48 years old, obese, female patient of enterocutaneous fistula, with short neck required CVC for parenteral nutrition. In the absence of USG, a therapeutic bed and prominent anatomical landmarks,

we anticipated difficulty. After aseptic preparation and local anesthetic infiltration, the patient was asked to perform VM. After a test puncture with a pilot needle, the needle for passage of guidewire was inserted into right IJV just lateral to carotid pulsation, followed by successful guide wire placement. The central catheter was then placed following a repeat VM.IJV cannulation is a common technique for blind external landmark guided CVC, wherein inadvertent

Figure 1: IJV cross section before VM.

Figure 2: IJV cross section after VM.

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 101

letters to editor

carotid artery puncture, nerve injury and airway compromise are frequently encountered complications. Trendelenburg position, hepatic compression, positive intra thoracic pressure and VM1,2 increase the cross sectional area of central veins significantly (>20% ) and reduce their collapsibility in spontaneously breathing patients3 as shown in Figure 1 and 2. Moreover, VM opens the valves in the larger veins (especially EJV) by distending them. Increased diameter of IJV and EJV

combined with opening of the venous valves makes needle placement, passage of guidewire and catheter easier,4 thereby reducing the complications. Feasibility of performing VM in both intubated and ventilated patients (passive VM), as well as in spontaneously breathing patients (active VM) allows this technique to be used in a wide range of patients. Clinicians should thus be aware of this simple technique to enhance the success rates of CVC in wards and emergency settings.

1. Lobato EB, Florete OG Jr, Paige GB, Morey TE. Cross sectional area and intravascular pressure of the right internal jugular vein during anesthesia.effect of Trendelenburg position, positive intrathoracic pressure, and hepatic compression. J Clin Anesth 1998; 10:1-5. [Medline]

2. P. Cowlishaw, P. Ballard. Valsalva Manoeuvre

For Central Venous Cannulation Anesthesia 2007;62:640

3. Bellazzini MA, Rankin PM, Gangnon RE, Bjoernsen LP. Ultrasound validation of maneuvers to increased internal jugular vein cross section area and decreased compressibility. Am J Emerg

Med. 2009 May;27(4):454-9. doi: 10.1016/j.ajem.2008.03.034. [Medline]

4. Suzuki T, Takeyama K, Hasegawa J, Nishiyama J, Takiguchi M. Valsalva maneuver prevents guide wire trouble associated with 22-g safe guide. Tokai J Exp Clin Med. 2001;26(3):113-8. [UnboundMedline] [Medline]

REFERENCES

Accidental intra arterial injection of diclofenac sodium and their consequences: report of two casesSukhen Samanta MD,PDCC* and Sujay Samanta MD**

*Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014 (India); Cell: 08004967745; Email: dr.sukhensamanta@gmail.com**Department of Anesthesiology & Intensive Care, Post Graduate Institute of Medical Education & Research, Channdigarh 160012 (India)

Citation: Samanta S and Samanta S. Accidental intra arterial injection of diclofenac sodium and their consequences: report of two cases. Anaesth Pain & Intensive Care 2013;17(1):102-103

Dear Editor,

Diclofenac is a nonsteroidal anti-inflammatory drugs (NSAID) used as an analgesic reducing moder-ate pain in intra operative and post operative, com-monly used along with general anesthesia cases for analgesia purpose. Several commertial preparations are available. Accidental intra-arterial injections of an-esthetic drugs cause arterial spasm with variable poor results.[1] There are some drugs which are given un-intentionally or intentionally without any bad con-sequences.[2] Controlled study helps in identification of the pathophysiology underlying such arterial spasm following such intra-arterial injections,but have logical limitation.[2] Unintentional use of intra-arterial route has not been reported for its adverse effects with di-clofenac sodium. We report two cases of unintentional intra-arterial injection of different preparation of di-clofenac with two different outcomes.

Our first case was a 39 year old, obese (body mass in-dex 32) gentleman, with black complexion posted for

removal of retroperitoneal tumor(sarcoma) under gen-eral anesthesia. Lower thoracic epidural insertion for analgesia was tried but failed due to difficult anatomy. Induction of anesthesia was done with propofol, fen-tanyl (in view of obstructive sleep apnea) and vecuro-nium In view of expected major blood loss post in-duction arterial line was inserted for real time blood pressure monitoring and blood gas analysis. Intuba-tion and intra operative course was uneventful. He was given intra-arterial alcohol (benzyl alcohol) based preparation of diclofenac (Volicad™,Cadila®) 100 mg in the late intraoperative period for postoperative pain relief. Following recovery from anesthetic effect he complained of pain in his right hand. Rapid search of the cause revealed diclofenac injection unintentionally through a tri-way with 10 cm extension line attached to right radial artery. Bluish discoloration was noted on two fingers in radial artery distribution noticed 45 minutes after injection. Treatment initiated with intra arterial heparin 2.5000 IU and intravenous preservative free lidocaine 80 mg. He developed gangrene (Fig 1)

102 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

Fig 1: Bluish discoloration of the hand after intra arterial diclofenac injection.

catastrophy after unintentional arterial injection.[3] We consider, benzyl alcohol, preservative used in nonaqueous preparation of diclofenac (Volicad™) may be the cause of vasospasm due to endothelial edema and capillary endothelial dysfunction in the first case.[4] Vasospasm, intravascular thrombosis, chemical en-doarteritis are the proposed pathophysiological mecha-nism.[5] Complications of intra-arterial injection of non aqueous agents (phenytoin, propofol) [6] and high-ly alkaline drugs (thiopentone)[1] are known for years, on the contrary drugs like atropine, vecuronium, fenta-nyl have been used without untoward effects.[7] Mem-brane soluble drugs are known to cause more compli-cations. Multiple theories are postulated for the cause of arterial spasm, or hypoperfusion which is the final common pathway for limb ischemia. Iatrogenic com-plications are prone to occur in postoperative setting when patient is recovering from anesthesia. Intention-al induction using IA route was reported in children from operation theatre, in emergency situation, where intravenous access was difficult.[8] Though guidelines are not available, case reports and review reported that water soluble drugs and drug’s with pH closer to arte-rial blood pH may be used through IA route. Different preparation of the same analgesic diclofenac never been reported to the best of our knowledge. In conclusion although aqueous preparation with preservative free of diclofenac administration didn’t match the results of nonaqueous preparation of same drug, definitive state-ment regarding its safety during intra arterial injection and causative agent for arterial spasm couldn’t be for-mulated. Any way intention intra arterial diclofenac of any preparation should be avoided at any cost.

after 2 days of accidental injection and had undergone amputation of distal part of his affected finger but on radiological examination his brachial arterial cross sec-tion area and flow was normal.The second patient was a 19 year old young adult post-ed for craniotomy for meningioma. In view of major neurosurgical procedure and highly vascular meningio-ma, arterial line inserted in left radial. In tra operative course was uneventful. He was extubated in full con-scious status. Aqueous based preparation of diclofenac (Voveron™, Novatis®) was given accidentally through intra-arterial cannula in the postoperative period by nurse posted in post anesthesia care unit. This time the patient complained of burning sensation along arterial course. Immediate heparin and lignocaine administered in arterial line and radial artery Doppler shown nor-mal arterial pulse waves. and remain uncomplicated even after 7 days follow up with Doppler study.Many case reports have been published on upper limb

1. Stone HH, Donnelly CC.The acciden-tal intraarterial injection thiopental. Anesthesiology1961;22:995-1006

2. Ahmed F. Ghouri .Accidental intrarterial drug injection via intravascular catheters placed on the dorsum of the hand. Anesth & Analg. 2002;95:487-491

3. Lindfors NC, Vilpponen L, Raatikainen T. Complications in the upper extremity follow-ing intra-arterial drug abuse. J Hand Surg Eur

2010;35:499-5044. Knill RL, Evans D. Pathogenesis of gangrene

following intra-arterial injection of drugs: a new hypothesis. Can Anaesth Soc J. 1975 Nov;22(6):637-646

5. Sen S, Chini EN, Brown MJ. Complications after unintentional intra- arterial injection of drugs: risks, outcomes, and management strategies. Mayo Clin Proc 2005;80:783-795.

6. Bernard G. Fikkers, Eveline W. Intra-arterial

injection of anesthetic drugs. Anesth & Analg 2006;103:792-794.

7. Nicolson SC, Pasquariello CA, Campbell FW. Intra-arterial injection of pancuronium and fentanyl: an alternative. Crit Care Med 1988;16:915

8. Joshi G, Tobias JD. Intentional use of intra-arterial medications when venous access is not available. Paediatr Anaesth 2007;17:1198-1202.

REFERENCES

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 103

Precision PlusTM SCS System for PainPrecision Plus is the only system with SmoothWaveTMTechnology. There are eight contacts on each lead, and the therapy is delivered through the individual contacts. SmoothWave Technology gives your physician the ability to precisely control the stimulation being delivered from each and every contact on the implanted leads.Precision Plus also offers a small implant with a contoured, oval shape. In fact, the PrecisionTM IPG has the smallest “footprint”

of any rechargeable SCS device. Precision Plus is the only SCS system to offer a cordless remote with a 24-inch communication range. This remote is easy to use and is designed to put pain control at your fingertips Precision Plus offers a cordless on-the-go charger.

New drug delivery system uses magnetismResearchers in Children’s Hospital Boston introduce a tiny implantable device whose membrane releases drugs with extreme precision, on demand, when triggered by a magnetic field, a tiny, implantable device that releases the medication through a membrane whose porousness responds to the switching on or off of a magnetic field. The membrane is embedded with nano particles that contain magnetite, a mineral with natural magnetic properties. When a magnetic field near the device turns on, the nanoparticles heat up, collapsing the gels in the membrane so that the drug can pass through the open pores. When the field turns off, the cooling membrane causes the gels to re-expand, thereby cutting off the drug.

TAP 20™In many ambulatory care settings, blood sampling can be a significant barrier to adoption of point of care testing, as it requires trained personnel, creates anxiety and discomfort for patients, and can disrupt workflowTAP 20™, Seventh Sense’s lead product in development, collects up to 20 microliters of whole blood – sufficient volume for many routine point-of-care blood tests, and has several advantages: It is painless for the patient, sample is contained until used for testing, no sharps disposal In addition to TAP 20™, Seventh Sense is developing TAP 100™ for point-of-care panels and tests requiring up to 100 microliters of blood; the development of TAP 100 is supported by a grant from the Gates Foundation http://www.7sbio.com/products/tap-products.html

New Cannula Design with Integrated Local Anesthetic Delivery SystemOliver Blackwell, an English product designer, has come up with a new device for easing the pain of intravenous cannula

insertions by automatically delivering local anesthesia through a small needle before the big one is stuck in. http://www.plymouth.ac.uk/pages/view.asp?page=38663

Trends & TechnologyNeuroSENSE NS-701 Electroencephalogram Monitor from NeuroWaveThis bilateral brain monitor, designed with independent indices for each brain hemisphere, now comes with a 10.4 monitor screen. Delay-free tracking of patient state via low-noise WAVCNS1 bilateral indexesWAVCNS (Wavelet Anesthetic Value for Central Nervous System) indexes provide instantaneous tracking of the patient state Automatic trending facilitates immediate response without increasing the index noiseTrue bilateral monitoring with great inter-hemispheric reproducibilitySuperior prediction of loss of consciousness Linear response to increasing EEG suppression Advanced automated artifact detection and removal Electro-surgical interference detection and filtering Cardiac defibrillation proof Continuous measurement of electrode-skin contactsCompliant with the guidelines of International Federation of Clinical Neurophysiology (IFCN) and American Clinical Neurophysiology Society (ACNS) Availability of raw EEG data Transparent, published algorithmhttp://www.medgadget.com/2011/09/the-new-neurosense-ns-701-electroencephalogram-monitor-from-neurowave.html

Mindray A5 Anesthesia DeviceMindray out of Shenzhen, China has a 15≅ touchscreen for

selecting settings, as well as a central brake and an integrated cable sweeps for mobility.A5 is the first and only anesthesia machine that conforms to the IHE (Integrating the Healthcare Enterprise) Patient Care Domain (PCD) profile. At no additional charge, every A5 provides data output in the industry standard HL7

protocol. HL7, with the IHE PCD profile, is recognized among anesthesia information management systems (AIMS) and electronic medical records (EMR) systems as the demonstrated industry standard for unambiguous interoperability. The A5 provides a range of advanced ventilation modes enabling effective care across different patient acuity types. Integrated spirometry offers additional information which enhances careful decision making. The unique, auxiliary O2/Air Blender reduces the risk of surgical fires by controlling the oxygen concentration under the drape, near the patient’s head and chest. http://i r .mindray .com/phoenix .zhtml?c=203167&p=irol -newsArticle&ID=1532197&highlight=

Continuous Hemoglobin Monitor Masimo‘s noninvasive hemoglobin monitor is a part of Masimo Rainbow SET. SpHb monitoring clearly changes clinician behavior and results in lower intraoperative blood transfusion rates and lower overall blood utilization. http://www.medgadget.com/2010/10/masimos_continuous_hemoglobin_monitor_helps_reduce_blood_transfusions.html

104 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

cliniquiz

cLINIQUIZ

Acute respiratory distress syndromePranav Bansal*, Gaurav Jain**, Meenu Agarwal*, Karamveer Singh*

*Dept. of Anesthesiology, BPS GMCW, Khanpur Kalan, Sonepat, Haryana (India)**Teerthanker Mahaveer Medical College, Moradabad, UP (India)

A victim of polytrauma has been operated for fixation of fractures of both femurs and left humerus. He is shifted to surgical intensive care unit and transfused with 6 to 7 units of blood. On 3rd postoperative day, he develops sudden shortness of breath with tachycardia and tachypnoea. On examination, his HR is 144/min, BP 104/60 mmHg, Resp. rate: 42/min and SpO2: 96%. Chest X-ray reveals haziness and opacities in both of the lung fields, while ABG’s reveal pH: 7.21, PaO2: 46 mmHg, PaCO2: 38mmHg, HCO3: 14mmHg. A presumptive diagnosis of Acute Respiratory Distress Syndrome (ARDS) is made and ventilatory support is initiated after endotracheal intubation. (Please select one correct option)

Q. 1: All of the following are common causes of ARDS except?a. Sepsis b. Pulmonary contusionc. Aspiration pneumoniad. Pneumonia

Q. 2: Which of the following is not a presenting feature in the early stages of ARDS?a. Hypocapniab. Hypoxemiac. Decreased lung complianced. Interstitial edema

Q. 3: Which of the following is not used for evaluating the severity of ARDS?a. PaO2/Fio2<300b. PaO2/Fio2<200c. Radiographic infiltratesd. Pulmonary artery occlusion pressure (POAP) >18

mmHg

Q. 4: The following is not associated with increased mortality in a patient with ARDS?a. Advanced diabetes mellitusb. Chronic alcohol intakec. HIV diseased. Organ transplantation

Q. 5: Which of the following statement is correct?a. Presence of alveolar type-III procollagen peptide is

associated with increased mortalityb. Mortality is higher in cases with ARDS due to

pulmonary causes as compared to non-pulmonary causes

c. Features of ARDS are confined to the lung initiallyd. COPD is the most common cause of direct lung injury

leading to ARDS

Q. 6: Which of the following statement is correct regarding ARDS: a. All patients go through three pathophysiological

phases of ARDS (exudative, proliferative and fibrotic phases)

b. Prognosis is not age relatedc. Full respiratory recovery is expected in most survivors

after 12 monthsd. Echocardiography can help to identify lung injury

Q. 7: Which of the following statement regarding management strategy in ARDS is incorrect?a. Prone positioning provides temporary improvement

in oxygenationb. Conservative fluid management reduces extravascular

lung waterc. Steroids given in acute phase decrease inflammation

and severity of ARDSd. Administering nitric oxide provides long term

improvement in oxygenation

Q. 8: Which of the following is incorrect regarding mechanical ventilator support in ARDS?a. Volume/pressure control mode should be instituted

after taking the patient on ventilatory supportb. Improving lung compliance can be identified by falling

peak pressurec. Recommended ventilator settings include tidal volume

of 6-8 ml/kg, PEEP 8-12 cm H2O and FiO2 of 80-100% for first few hours

d. Pressure control (PC) ventilation has been shown to increase lung injury compared to volume control (VC) mode

Q. 9: All of the following ventilator settings have been shown to improve outcomes in patients with ARDS except: a. Decreasing inspiratory flow rate if breath stacking or

patient-ventilator dyssynchrony occurs

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 105

cliniquiz

b. Inverse ratio ventilation with I:E ratio 2:1 to 3:1c. Adjusting ventilator settings to deliver low tidal

volumes of 6-7 ml/kg d. Setting peak inspiratory pressures to < 30 cm H2O

Q. 10: Which of the following is not true regarding perflourocarbons (PFC)?a. PFC have a high surface tension to compensate for

deficient surfactant b. They have a density higher than body fluidsc. They have anti-inflammatory properties in the alveolar

spaced. They provide liquid PEEP in dependent lung

ANSWERSAns. 1(b): Head Injury, inhalational injury, near drowning, fat embolism, reperfusion injury, pancreatitis, burns, trauma, drug overdose and transfusion of blood products are a few rare causes of ARDS.Ans. 2(b): Hypoxemia does not occur early in ARDS as patient compensates for decreasing O2 levels by increasing respiratory effort leading to hypocapnia. As disease progresses over next 6-48 hrs, rising tachycardia, tachypnoea, ventilation-perfusion mismatch, lung water, crepts and crackles lead to deterioration in condition.1

Ans. 3(d): The European Society of Intensive Care Medicine (endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition in 2012. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (PaO2/FIO2 ≤ 300 mm Hg), moderate (PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The diagnosis of the ARDS is predominantly made on a clinical basis, and pulmonary artery catheters or PAOP no longer have a major role in the diagnosis and management of ARDS.2,3

Ans. 4(c): Increased mortality is observed in immunocompromised patients suffering from ARDS. As an HIV positive case has enough immunocomptence in

early phase, the risk of increased mortality has not been reported in trials.4

Ans. 5(a): Alveolar type III procollagen peptide is a marker of pulmonary fibrosis and progression to fibrotic phase of ARDS. No difference in mortality was noted either due to direct or indirect cause in a large cohort study. Release of cytokines and inflammatory mediators initiate systemic manifestations leading to hypotension, tachycardia and myocardial depression. Pneumonia is the most common cause of direct lung injury leading to ARDS.Ans. 6(c): All patients do not undergo the three phases of ARDS. Prognosis is poor in patients who are staged in fibrotic phase, elderly or immunocompromised. Echocardiography helps to exclude left atrial hypertension, required for diagnosis of ARDS. Ans. 7(d): Prone positioning improves alveolar recruitment and oxygenation in basal zones of lung. The conservative fluid strategy has shown to reduce lung water and improves oxygenation index, lung injury score and the number of ventilator free days. Routine use of corticosteroids is not advocated, especially in the acute phase of ARDS, due to infection potentiating and myopathy related issues. Steroids have shown to reduce the severity of inflammations and hence fibrosis in fibrotic stage, though no reduction in mortality was observed in any stage of ARDS. Nitric Oxide provides short term increase in oxygenation, but presently is not recommended based on clinical evidence against efficacy of therapy.1,5

Ans. 8(d): Alveolar recruitment leads to decrease in lung resistance, which leads to a fall in peak pressure (i.e. pressure required to open the alveoli) on observing ventilator trends. PC mode has shown to decrease lung injury compared to VC mode.Ans. 9(b): If breath stacking or patient-ventilator dyssynchrony occurs, inspiratory flow rate and the level of sedation should be increased.3

Ans.10(a): PFC’s are biologically stable, inert, twice as dense as water and settle down in dependent portions of the lung where they improve oxygenation. The surface tension of PFC is remarkably low (12-18 dyne/sec) because of low intermolecular forces, which aids in alveolar recruitment.6

1. Peters CW, Yu M, Sladen RN, Gabrielli A. Acute Lung Injury and Acute Respiratory Distress Syndrome. Ch. 136. Civetta, Taylor, & Kirby’s: Critical Care; Lippincott Williams & Wilkins, 4th Edition 2009.

2. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS.Acute respiratory distress syndrome: the Berlin Definition.JAMA. 2012

Jun 20;307(23):2526-33. doi: 10.1001/jama.2012.5669.

3. Acute Lung injury and acute respiratory distress syndrome. Lorraine B Ware, Gordon R Bernard. Ch 75; pp 571-9. Shoemaker Textbook of Critical Care.5th ed. Elsevier Saunders 2005.

4. Tellez M, Pedro A, Damluji, Abdulla et al. Human Immunodeficiency Virus Infection and Hospital Mortality in Acute Lung Injury Patients.

Crit Care Med. 2010;38(7):1530-5. 5. Bruce D. Levy, Steven D. Shapiro. Acute

Respiratory Distress Syndrome. Ch 30, Pg 290-6. Harrsion’s Pulmonary and Critical Care Medicine.17th edition. MacGraw Hill publications.

6. U. Kaisers, K. P. Kelly, T. Busch. Liquid ventilation. British Journal of Anaesthesia 2003;91(1):143-51.

REFERENCES

106 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

cALeNDAR oF eVeNTsMay 2-5, 2013; Singapore, Singapore5th Association of South-East Asian Pain Societies Conference - Pain: The Unseen Disease aseaps2013@kenes.com http://www.aseaps2013.org/

May 2-5, 2013; Boston, Massachusetts 02210, United States38th Annual Regional Anesthesiology and Acute Pain Medicine Meeting asra@kenes.com http://www.kenes.com/asraspring/

May 4-5, 2013 -Northbrook, Illinois, United StatesCritical Care Echocardiography

May 4-7, 2013 -San Diego, California, United StatesInternational Anesthesia Research Society 2013 Annual Meeting

May 4-8, 2013 -Melbourne, AustraliaAustralian & New Zealand College of Anaesthetists 2013 Annual Scientific Meeting anzca2013@wsm.com.au

May 6-9, 2013 -Athens, Greece1st Annual International Conference on Health & Medical Sciences atiner@atiner.grhttp://www.atiner.gr/healthsciences.htm

May 8, 2013 -Dundee, United KingdomAdvanced Airways Techniques Course

May 8, 2013 -Destin, Florida, United StatesUltrasound Guided Regional Anesthesia and Vascular Access Workshop info@nwas.com

May 22-24, 2013 -Bournemouth, United KingdomObstetric Anaesthesia 2013 http://www.oaa-anaes.ac.uk/content.asp?ContentID=492

May 22-25, 2013 -Rovinj, Croatia5th European-American Anesthesia Conference

May 23-26, 2013 -Toronto, Ontario, Canada4th International Congress on Neuropathic Pain Venue: Metro Toronto Convention Centre

May 30 - June 1, 2013 -Amsterdam, Netherlands1st World Congress on Abdominal and Pelvic Pain

May 31 - June 2, 2013 -Aurora, Colorado, United States2013 International Symposium on the Pediatric Airway Venue: University of Colorado School of Medicine Anshutz Medical Campus

June 1 – 4th. Barcelona, Spain.ESA Euroanaesthesia Info: www.euroanaesthesia.org

June 6 – 8th. 28th, Barcelona, Spain. Annual Meeting of the European Association of Cardiothoracic Anesthesiologists. Info: www.eacta.org also eacta2013@mci-group.com

June 8-10, 2013 -Arlington, Virginia, United StatesAssociation of Interventional Pain Physicians 15th

Annual Meeting Venue: Crystal Gateway Marriott

June 12-15, 2013 -Rotterdam, Netherlands24th Annual Meeting of the European Society of Paediatric and Neonatal Intensive Care

Venue: De Doelen Congress Centre

June 12 – 15th. ASAIO 59th Annual Conference.Info: www.asaio.com

June 12-15, 2013 -Sydney, AustraliaInternational Liver Transplantation Society 19th Annual International Congress Venue: Sydney Convention & Exhibition Centre

June 13-15, 2013 -Vancouver, British Columbia, Canada9th Annual Advanced Learning in Palliative Medicine Conference Venue: Marriott Pinnacle Hotel

June 14-15, 2013 -Istanbul, TurkeyMedicReS International CME Conference on “Good Clinical Research” Venue: Grand Cevahir Hotel & Convention Center

June 21-24, 2013 -Calgary, Alberta, Canada2013 Canadian Anesthesiologists’ Society Annual Meeting Venue: Telus Convention Centre

July 13-16, 2013 -Warsaw, PolandIPTA 7th Congress on Pediatric Transplantation

July 14-27, 2013 -Nairobi, KenyaAnesthesia on Safari 12-Day African Safari

July 19, 2013 -Falmouth, Massachusetts, United StatesUltrasound Guided Regional Anesthesia and Vascular Access Workshop

July 19-21, 2013 -Northbrook, Illinois, United StatesDifficult Airway Management: A Critical Care Approach

July 25, 2013 -Northbrook, Illinois, United StatesEssentials of Mechanical Ventilation for Providers

July 26-28, 2013 -Northbrook, Illinois, United StatesMechanical Ventilation: Advanced Critical Care Management

September 4-7, 2013 -Glasgow, United Kingdom32nd Annual ESRA Congress 2013

September 8-11, 2013 -Vienna, AustriaESOT Vienna Congress 2013: the 16th Congress of the European Society for Organ Transplantation

September 19 – 21th. Brno, Czech Republic. XX Annual Congress Czech Society of Anesthesiology and Critical Medicine www.csarim2013.cz

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 107

‘My Most Unforgettable experience’®

Me and my fibromyalgiaThe clinical definition of chronic fibromyalgia syndrome (FMS) when broken down is: chronic means on-going; fibro means connective tissues, myo means muscles, algia means a painful condition, and syndrome means a group of symptoms. Its many symptoms are not shared by every sufferer, or in the same combination, however some are: body-wide pain, muscle spasms, fatigue and depression. Modern medicine offers no hope, saying FMS is a lifelong, degenerative disease with no known cause or cure and can only be managed with drugs with lousy side effects making you worse over time.My book creates a paradigm shift in understanding FMS by showing it is a curable, symptom itself: the natural effects of the atlas subluxation, and the subsequent brain-stem injury, cervical myopathy and spinal misalignments this subluxation causes. These effects are hyper-activation and hyper-sensitization of the central nervous system, distortion of regulatory signals from the hypothalamus to and from the body, and the cascade of system-wide malfunctions of FMS.The atlas subluxation is caused by trauma, most commonly whiplash from motor vehicle accidents. Other traumas are: a jarring fall; a bump on the head; a twisting-lifting accident; lifting something heavy; poor head posture; a poor golf swing; carrying heavy babies; neck strain from a psychological trauma; general anesthesia causing neck muscles to go limp, allowing the atlas to shift, and more. Traumas can compounded over years, often triggering FMS with a minor “last-straw injury.” FMS can also be triggered by major trauma. Compounding traumas to my head and neck beginning with a blow to the head and whiplash from an auto accident 35 years prior, finally exacerbated by a minor exercising accident further displacing my atlas, triggered full-blown FMS, taking three years to completely disable me.I became bed-ridden from pain for nearly two years, and housebound for ten. Knowing what caused it, I saw over a dozen doctors before I received a near-correct diagnosis. I brought my diagram of cause and list of questions to each doctor, and was dismissed. After leaving the care of the medical profession, I saw several chiropractors before finding one that could adjust my atlas. This was the turning point where I began taking my life back from this horrific disorder. I then developed my protocol for a lasting cure that is maintainable and real in alternative medicine and naturopathic therapies. FMS sufferers must seek the care of an upper cervical chiropractor to get their atlas, neck and spine x-rayed and aligned. My protocol begins here and includes therapies that support healing and rehabilitating a degenerated body from the ravages of FMS. These include classical constitutional homeopathy, nutrition therapy, gentle physical therapies, psychotherapy and stress reduction, an optional dual-neurotransmitter reuptake inhibitor for rebalancing two key neurotransmitters involved in pain and depression: serotonin and norepinephrine.In four years my body became FMS free. It may not take this long for others, I was an extreme case, my atlas being severely misaligned for 13 years, the worst my chiropractor had ever seen.The medical profession and scientific community remain at a loss about a cause or cure for FMS because they know little about the science of chiropractic or how to read spinal x-rays for subluxations, and are therefore suspicious. Also, scientists who must quantify and measure every thing cannot quantify and measure common sense. For example, both professions ascertained 90% of reported FMS patients are women, and10% men, theorizing it may be that FMS is carried on female chromosomes, and triggered by female hormones and emotions. However, common sense dictates only 10% are men because they have stronger necks, shoulders and backs, being less vulnerable for head and neck trauma resulting in atlas subluxations. This is missing the scientific boat. Another example is psychologists’ view of FMS almost exclusively attributing it to psychological stress, somatoform pain disorders, and clinical depression whose criteria do not fully match or account for all possible FMS symptoms.The pitfall of specialties is viewing a condition through the lens of the specialty. The fact is, stress exacerbates any condition, even the common cold, however it cannot be concluded stress caused it. Stress exacerbates all FMS symptoms because it lives in the central nervous system.My book discusses chronic pain biochemistry, shows specific nutrition helps reverse energy deficit, completely clarifies FMS symptoms, debunks modern myths and theories of physical and psychological causes, and tells my story navigating the labyrinth of regular and alternative medicine to isolate the cause, and develop a protocol for a lasting cure.I have been FMS free for over three years. I spent ten years exhaustively researching and writing this book while healing this condition. It now enjoys endorsements from the International Chiropractic Association, the National Upper Cervical Chiropractors Association, the National Massage Association, the Oregon Health and Science University’s Fibromyalgia Information Foundation, and a five star review on Amazon.FMS is a dark tunnel where its sufferers get lost in despair. I want to stand at the end of this tunnel with bells and whistles, and shine a light bright enough for all to see, and show the millions of FMS sufferers how to guide themselves back out into life again. This is my mission.I am a living proof that this condition can be cured, and you do not have to wait for modern medicine or science, whose treatments are based on trends likely considered obsolete tomorrow, to figure it out for you. Educate yourself, take charge, seek an upper cervical chiropractor, and begin now taking back your life!

From “Curing Chronic Fibromyalgia-Choosing What Works” by Valerie Lumley,

28 Montsalas Drive Monterey, California 93940 (USA) The book is available at www.thefibrocure.com

108 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013

cLINIPIcs

optimising the length of i-gelTariq Hayat Khan, Amna Ghayas, Ayesha, Shiraz Naeem, Naeem Khan

KRL General Hospital, Islamabad (Pakistan)

i-gel is being widely used as a supraglottic airway device, in spontaneously breathing patients as well as for mechanical ventilation. It has been used as an emergency use airway device with success. The manufacturer has launched i-gel in many sizes. Each size is recommended for patients of a particular weight category, e.g. size 1 for 2-5 kg, size 1.5 for 5-12, size 2 for 10-25 and size 2.5 for 25-35 kg body weight. We observed that the length of the connector as well as the shaft of the i-gel for these smaller sizes is in excess of what is required, thus adding to dead space and difficulty in holding it firmly in place. No filter was used in both of these patients to reduce the resistance to spontaneous breathing and the dead space.

Figure 1&2: Intact i-gel size 1.5 and 2 in use. Note the extra long shaft and the connector

Figure 3: Size 2 i-gel in use, which was cut short by 4 cm Figure 4: An intact and a cut i-gel size 2