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Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
BACKGROUND: General anesthesia with opioids provides good operative conditions for ocular surgery in children; however, postoperative pain management remains a significant problem. Regional anesthesia is commonly used as an adjunct to general anesthesia in children. We compared the efficacy and safety of subtenon block (SB) versus IV fentanyl for perioperative analgesia in pediatric cataract surgery. We hypothesized that perioperative analgesia using SB may reduce the requirement of postoperative rescue analgesia compared with fentanyl. METHODS: This was a prospective, randomized, controlled, double-blind trial. One hundred fourteen ASA I and II children (6 mo-6 yr) undergoing elective cataract surgery in one eye under general anesthesia were studied. Children were randomly allocated to one of the two groups, i.e., Group SB (n = 58) or Group F (n = 56) after securing the airway. Children in Group SB received SB with 0.06-0.08 mL/kg of 2% lidocaine and 0.5% bupivacaine (50:50) mixture and simultaneous 0.2 mL/kg normal saline IV, whereas children in Group F received 1 microg/kg (0.2 mL/kg of 5 microg/kg) of fentanyl IV and simultaneous subtenon injection with normal saline (0.06-0.08 mL/kg). Surgery started after 5 min of study drug administration. Postoperative assessment for pain, sedation, and nausea/vomiting was done at 0.5, 1, 2, 3, 4, and 24 h. The primary outcome was number of patients requiring rescue analgesia during the 24-h study period. Secondary outcomes assessed were pain and sedation scores, time to first rescue analgesia, incidence of occulocardiac reflex, and nausea/vomiting. RESULTS: The number of patients requiring rescue analgesia during the 24 h was significantly less in Group SB (n = 17/58, 29.3%) compared with Group F (n = 39/56, 69.6%, P < 0.001). The postoperative pain scores were statistically lower in Group SB at all time intervals. The median (range) time to first analgesic requirement was significantly prolonged in Group SB (16 [2-13] vs 4 [0.5-8.5] h in Group F)(P < 0.001). Sedation scores at (1/2) h were comparable, after which significantly more children were anxious or crying in Group F compared with Group SB in which more children were calm, sitting, or lying with eyes open and relaxed (P < 0.05). A significantly higher incidence of oculocardiac reflex was recorded in Group F versus Group SB (P = 0.019). No complication related to SB was noticed. CONCLUSIONS: SB is a safe and superior alternative to IV fentanyl for perioperative analgesia in pediatric cataract surgery.
Latest citations:
Curr Opin Ophthalmol. 2009 Oct 22;:
19855277
Duke University Eye Center, Duke University Medical Center, Durham, North Carolina, USA.
PURPOSE OF REVIEW: Cataract surgery is the most commonly performed intraocular surgery in the pediatric population worldwide. Although the basic surgical techniques have not significantly changed over the last several years, there are many related issues under continual debate and research. These include use of local perioperative anesthesia, capsular management, type and power of intraocular lenses (IOLs), sutured IOLs, and risk of subsequent glaucoma. This review will primarily focus on postsurgical outcomes and IOL-related controversies. RECENT FINDINGS: The just completed Infant Aphakia Treatment Study aims to answer questions regarding visual outcomes with primary IOL implantation versus contact lens use in children less than 7 months old with a unilateral congenital cataract. But correct IOL selection is controversial as recent studies highlight difficulties with biometry measurement and IOL calculations in the entire pediatric population. We also discuss the risk of late suture breakage and dislocation with sutured IOLs and the risks of aphakic glaucoma. SUMMARY: Worldwide experiences with pediatric cataract surgery and IOL implantation are constantly evolving. Expectations of good outcomes by the patients, families, and surgeons are also increasing therefore continued efforts to improve techniques and formulas specific to the pediatric population are critical.
Br J Anaesth. 2009 Aug 25;:
19706631
Department of Anaesthesiology and Intensive Care and.
BACKGROUND:/st> Vitreoretinal (VR) surgery is associated with moderate to severe pain and significant postoperative nausea and vomiting (PONV). The study aimed to assess the effectiveness of sub-Tenon's block for providing perioperative analgesia in children undergoing VR surgery. METHODS:/st> In a randomized, observer-blinded trial, after obtaining institutional ethical committee approval and parental consent, 200 ASA grade I-II children aged 5-16 yr were allocated to receive either a sub-Tenon's block (Group SB) or 2 microg kg(-1) i.v. fentanyl (Group F) after induction of anaesthesia and topical anaesthesia of the conjunctiva with proparacaine 0.5% drops. Patients in Group F received fentanyl 0.5 microg kg(-1) and those in Group SB were given a corresponding volume of normal saline i.v. every hour from preloaded syringes. Increases in heart rate or mean arterial pressure by more than 20% of baseline were treated with additional 0.5 microg kg(-1) i.v. fentanyl boluses in both groups. The incidence of oculocardiac reflex (OCR), need for additional analgesics, postoperative pain, and PONV were recorded for the first 24 h after surgery. RESULTS:/st> More patients in Group F (47.96%) had moderate to severe pain in the first 24 h when compared with Group SB (31.36%)(P=0.023). The need for postoperative ibuprofen was higher in Group F (66.3%) compared with Group SB (47.95%)(P=0.012). The incidence of OCR was significantly higher in Group F (31.6%) compared with Group SB (5.1%)(P<0.001). The incidence of PONV was similar in both groups. CONCLUSIONS:/st> Sub-Tenon's block provides more effective analgesia than i.v. fentanyl for paediatric VR surgery.
Other papers by authors:
Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education & Research, Chandigarh-160012, India.
STUDY OBJECTIVE: To investigate the effect of parecoxib pretreatment with venous occlusion on propofol injection pain. DESIGN: Prospective, randomized, double-blinded, placebo-controlled study. SETTING: Operating room of a tertiary-care medical center. PATIENTS: 150 ASA physical status I patients scheduled for elective surgery. INTERVENTIONS: Patients were randomized to three groups of 50 patients each to receive pretreatment with normal saline (Group NS), parecoxib 20 mg (Group P20), or parecoxib 40 mg (Group P40). All groups underwent venous occlusion for two minutes before propofol was injected. All pretreatment drugs were prepared in 5 mL doses. MEASUREMENTS: Pain scores were obtained by a study-blinded observer during propofol injection following the different pretreatment solutions. MAIN RESULTS: Pain scores among the three groups were significantly different (P </= 0.001). In Group NS, 29 (58%) patients had pain during propofol injection compared with 22 (40%) Group P20 and 13 (26%) Group P40 patients (P </= 0.005). Pain was significantly reduced in Group P40 (P </= 0.001) compared with the control group. Moderate to severe pain was experienced by 18 (36%) Group NS and 4 (8%) Group P20 patients, whereas no Group P40 patient experienced moderate or severe pain (P < 0.001). Reduction in pain severity was statistically significant after pretreatment with either parecoxib 20 mg (P = 0.002) or parecoxib 40 mg (P < 0.001). CONCLUSION: Parecoxib 40 mg with venous occlusion is effective in reducing the frequency and severity of pain with propofol injection. Pretreatment with 20 mg of parecoxib reduces the severity of propofol injection pain significantly but does not reduce frequency compared with the control group.
Paediatr Anaesth. 2008 Mar 18;:
18363630
Cit:2
Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Postoperative pain assessment and management in preverbal children and children with cognitive impairment poses major challenges to pediatric anesthesiologists. An accurate diagnosis of extent of pain is the keystone for the successful management of pain. This article reviews the neurobiology of pain at birth, long-term consequences of early pain and different pediatric pain assessment tools used for postoperative assessment in infants, young children, and children with cognitive disabilities.
Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Background: The purpose of the study was to compare the success and ease of insertion of three techniques of laryngeal mask airway (LMA) insertion; the standard Brain technique, a lateral technique with cuff partially inflated and a rotational technique with cuff partially inflated. Methods: One hundred and sixty-eight ASA I and II children aged 6 months to 6 years undergoing short elective surgical procedures lasting 40-60 min were included in the study. A standard anesthesia protocol was followed for all patients. Patients were randomly allocated into one of the three groups i.e. standard (S), rotational (R) and lateral (L). The primary outcome measure of the study was success rate at the first attempt using three techniques of LMA insertion. Secondary outcomes measures studied were overall success rate, time before successful LMA insertion, complications and maneuvers used to relieve airway obstruction. Results: Successful insertion at the first attempt was significantly higher in group R (96%) compared with group L (84%) and group S (80%)(P = 0.03). Overall success rate (i.e. successful insertion with two attempts) was 100% for group R, 93% for group L and 87% for group S (P = 0.03). Time for successful insertion was significantly lower in group R compared with group L and S (P < 0.001). The incidence of complications was lower in group R. Conclusions: A rotational technique with partially inflated cuff is associated with the highest success rate of insertion and lowest incidence of complications and could be the technique of first choice for LMA insertion in pediatric patients.
BACKGROUND AND OBJECTIVE:To determine the management options and the indications for surgical intervention in Descemet's membrane detachment (DMD) after phacoemulsification. PATIENTS AND METHODS:Clinical records of 11 consecutive eyes (11 patients) with DMD were reviewed. All cases had undergone phacoemulsification with posterior chamber intraocular lens implantation. Patients with DMD involving one-third or more of the cornea were analyzed. RESULTS:All patients underwent clear corneal phacoemulsification. In three cases where the detachment was recognized intraoperatively, perfluoropropane gas was injected. Eight eyes (8 cases) had unexpected corneal edema detected as DMD postoperatively and managed by injecting perfluoropropane gas into the anterior chamber. Three eyes that required repeated surgical intervention postoperatively had more than 50% corneal involvement with significant separation of the membrane from the stroma and curling or folding of the membrane. At last follow-up, 10 eyes retained clear corneas and one had residual DMD not involving visual axis. All 11 eyes had best-corrected visual acuity of better than 6/12. CONCLUSION:DMD should be suspected in patients showing unexpected corneal edema postoperatively who have undergone uneventful phacoemulsification and be treated in a timely manner. Surgical intervention is recommended in cases with significant separation of the membrane from stroma and curling or folding of the Descemet's membrane.
From the Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
PURPOSE: To evaluate the outcomes of phacoemulsification with intraocular lens (IOL) implantation in eyes with uveitis. SETTING: Tertiary care center, Chandigarh, India. METHODS: Consecutive patients with uveitis and visually significant cataract were retrospectively studied for outcomes after phacoemulsification and implantation of a poly(methyl methacrylate)(PMMA) or a hydrophobic acrylic IOL. RESULTS: The study comprised 108 eyes of 81 patients (50 women, 31 men) with a mean age of 42.3 years +/- 13.98 (SD)(range 18 to 75 years) and a mean follow-up of 21.95 months (range 12 to 66 months). Etiology of uveitis was presumed tuberculosis (n = 24), Vogt-Koyanagi-Harada syndrome (n = 9), Behçet disease (n = 8), sarcoidosis (n = 5), ankylosing spondylitis (n = 4), serpiginous choroiditis (n = 2), and idiopathic (n = 29). The mean corrected distance visual acuity (CDVA) was 1.08 +/- 0.85 logMAR preoperatively and 0.42 +/- 0.78 D logMAR postoperatively; the improvement was statistically significant (P<.001, paired t test); Seventy-seven eyes (71.30%) achieved a CDVA between 0.00 logMAR and 0.30 logMAR (20/20 to 20/40 Snellen). Posterior capsule opacification (PCO) requiring neodymium:YAG capsulotomy occurred in 31 eyes (28.70%); posterior synechias in 27 eyes (25.00%); cystoid macular edema (CME) in 23 eyes (21.30%); recurrent uveitis in 6 eyes (5.55%); and epiretinal membrane formation, glaucoma, and iris bombe in 5 eyes (4.63%) each. CONCLUSIONS: Phacoemulsification with IOL implantation improved vision in most patients with coexisting cataract and uveitis. The main complications affecting visual outcomes were macular involvement, CME, PCO, and glaucoma. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.
Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education & Research, Sector-12, Chandigarh 160 012, India. ghaibabita@hotmail.com
PURPOSE OF REVIEW: The insertion of laryngeal mask airway is not always easy in children, and many techniques are described to improve success rate of placement. It is very important to determine the optimal insertion technique as unsuccessful prolonged insertion and multiple attempts are associated with adverse respiratory events and trauma in children. This article will review different techniques studied recently for the placement of classical laryngeal mask airway in children as well as recent findings of cuff pressure and depth of anesthesia for laryngeal mask airway placement. Laryngeal mask airway in children has undergone many modifications such as ProSeal laryngeal mask airway to improve its functioning. This article will also review different insertion techniques for ProSeal laryngeal mask airway. RECENT FINDINGS: Rotational technique with partially inflated cuff is reported to have the highest success rate of insertion and lowest incidence of complications for classical laryngeal mask airway in children. Clinical endpoints for cuff inflation are associated with significant hyperinflation and increased leakage around the laryngeal mask airway cuff. The inferences regarding the dosage of intravenous anesthetic agents and end-tidal concentration of volatile anesthetics in children to achieve adequate depth for laryngeal mask airway placement are very difficult to draw. ProSeal laryngeal mask airway is associated with a very high first attempt success and overall success of insertion in children. SUMMARY: Rotational technique may be considered as the first technique of choice for classical laryngeal mask airway insertion in children. The routine use of cuff pressure monitoring is mandatory during the use of laryngeal mask airway in children. Modification of laryngeal mask airway in children, that is ProSeal laryngeal mask airway, is promising and improves the success rate of insertion.
Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India. ghaibabita@hotmail.com
STUDY OBJECTIVE: To investigate the effect of adding midazolam to continuous epidural infusion of bupivacaine for postoperative analgesia in children. DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: Tertiary-care center. PATIENTS: 44 ASA physical status I and II children in age groups of two to 10 years, undergoing elective upper abdominal and flank surgery. INTERVENTIONS: At the end of surgery, patients were randomly allocated to receive epidural infusion of 0.125% bupivacaine alone (Group B) or with 20 microg/kg/hr midazolam (Group BM) for 12 hours at the rate of 0.2 mL/kg/hr. MEASUREMENTS: Pain, motor block, and sedation were assessed at predetermined times over 24 hours. Intravenous fentanyl was used as rescue analgesic for the first 12 hours, and tramadol for next 12 hours. Patients were followed at one week, one month, and one year for any neurological deficits. MAIN RESULTS: The number of patients requiring rescue analgesia during infusion was significantly lower in Group BM (7 vs. 17 in Group B; P < 0.001). Time to first rescue analgesia was significantly prolonged in Group BM compared with Group B (P < 0.001). Frequency of fentanyl (P < 0.001) and tramadol (P = 0.001) administration as rescue analgesia was significantly less in Group BM. Significantly lower median pain scores were obtained in Group BM than Group B at all time intervals (P < 0.05). Greater sedation scores were noted in Group BM at all time intervals postoperatively except at 4 hours (P < 0.05). No motor block was observed in any child during the study. No neurological deficit was reported in any child in the one year of follow-up. CONCLUSION: Addition of 20 microg/kg/hr of midazolam to postoperative continuous epidural infusion of 0.125% bupivacaine reduces the requirement for rescue analgesia in children following upper abdominal and flank surgery.
J Glaucoma. 2008 Mar ;17 (2):122-7
18344758
Cit:1
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
PURPOSE: To determine retinal nerve fiber layer (RNFL) thickness measurements in normal, ocular hypertensive (OHT), and glaucomatous Asian Indian eyes. METHODS: This prospective observational cross-sectional study included patients with OHT, primary open angle glaucoma (POAG), and age-matched normal controls. The global and 4-quadrant average RNFL thickness was measured using the Stratus OCT. The main outcome measures were differences in RNFL thickness measurements between the 3 groups. The discriminating power of each parameter was evaluated by calculating areas under receiver operating characteristic curves (AROCs). RESULTS: Twenty-three eyes of 23 POAG patients, 24 eyes of 24 OHT, and 48 eyes of 48 normal controls were analyzed. The superior, inferior, and global RNFL measurements were significantly thinner in OHTs compared with normals (P=0.031, 0.019, and 0.022, respectively). All 5 RNFL parameters were significantly thinner in the POAG group compared with OHT group (P<0.001). Parameters with largest AROCs for distinguishing glaucoma from OHT were average and inferior average RNFL measurements (0.989 and 0.979, respectively). Inferior and superior RNFL measurements had largest AROCs (0.717 and 0.700, respectively) to distinguish OHT from normal eyes. CONCLUSIONS: Stratus OCT detected significant quantitative differences in RNFL thickness between normal, OHT, and glaucomatous Asian Indian eyes.
Babita Ghai,
Jeetinder Kaur Makkar,
Jayamanti Bakshi,
Shelly Rana,
Rana Sandip Singh,
Sanjeev Bhagat
Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Institute Sciences and Research, Chandigarh, India.
Tracheoarterial fistula (TAF) involves erosion through the tracheal wall into the innominate artery resulting in bleeding. It is a rare but lethal complication of tracheostomy. Mortality is 100% without operative interference. Even with appropriate management, a survival rate of only 14.3% has been reported. We report a case of TAF in a child, where rapid institution of resuscitative and operative measures resulted in survival. Initial temporary control of bleeding was achieved by hyperinflation of cuff. Computed tomography (CT) angiography confirmed the diagnosis. The damaged segment of the eroded artery was resected and ligated. This case highlights the role of early diagnosis and prompt aggressive therapy for management of this potentially lethal complication.