Dr. Pushkar Desai

Background and Aims: General anesthesia is known to elicit stress response during endotracheal intubation, but the equally important period of extubation is usually not addressed. The aim was to compare dexmedetomidine and esmolol for attenuation of extubation response. Materials and Methods: In this prospective randomized double-blind trial, 100 American Society of Anesthesiologists I/II patients between 18 and 60 years of age undergoing abdominal and lower-limb surgeries were randomly allocated into two groups (n = 50 each). Patients in Group D received dexmedetomidine (0.5 μg/kg intravenous [IV] bolus) over 10 min and in Group E received esmolol (1 mg/kg bolus IV) before extubation. Hemodynamic parameters, namely, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), were compared at baseline, 10 min before extubation, at extubation, and at 1, 3, 5, 10, and 15 min thereafter. Data were expressed as mean ± standard deviation and analyzed using Student's unpaired t-test and Chi-square test. P <0.05 was considered statistically significant. Results: Patients in Group D exhibited lower HR, SBP, DBP, and MAP at the time of extubation till 15 min postextubation (P < 0.001) although the difference was clinically insignificant. Incidence of hypotension was similar in both groups (6% vs. 4%). Two patients in Group D developed bradycardia which was successfully treated with injection glycopyrrolate, while none exhibited any complication in Group E. Conclusion: Dexmedetomidine is a better, effective, and safe alternative to esmolol in attenuating stress response during extubation.

This study compares the emergence and recovery characteristics of sevoflurane, desflurane, and halothane in children undergoing adenoidectomy with bilateral myringotomy and the insertion of tubes. Eighty children 1-7 yr of age were studied. Thirty minutes prior to the induction of anesthesia, all patients received 0.5 mg/kg midazolam orally. Patients were randomly assigned to one of four groups: Group 1, sevoflurane induction and maintenance (S:S); Group 2, halothane induction and sevoflurane maintenance (H:S); Group 3, halothane induction and maintenance (H:H); or Group 4, halothane induction and desflurane maintenance (H:D). Tracheal intubation was facilitated with the use of a single dose of 0.2 mg/kg mivacurium. A Mapelson D circuit was used, and all patients received N2O:O2 60:40 for induction and maintenance at standardized appropriate fresh gas flow. Ventilation was controlled to maintain normocapnia. End-tidal concentration of anesthetics was maintained at approximately 1.3 minimum alveolar anesthetic concentration (MAC) (halothane: 0.56; sevoflurane: 2.6; desflurane: 8.3) until the end of surgery when all anesthetics were discontinued. Emergence (extubation), recovery (Steward score 6), and discharge times were compared among patients in the four groups using analysis of variance and Newman-Keuls tests P < 0.05 was considered significant. There were no significant differences among the four groups with respect to age, weight, duration of surgery, or duration of anesthesia. Emergence and recovery from anesthesia were significantly faster in the desflurane group (Group 4) compared with the sevoflurane and halothane groups (Groups 1, 2, and 3) (5 +/- 1.6 min vs 11 +/- 3.7, 11 +/- 4.0, 10 +/- 4.0 min and 11 +/- 3.9 min vs 17 +/- 5.5, 19 +/- 7.1, 21 +/- 8.5 min, respectively). There was a significantly greater incidence of postoperative agitation and excitement in patients who received desflurane (55%) versus sevoflurane (10%) and halothane (25%). There were no significant differences among the four groups with respect to the time to meet home discharge criteria (134 +/- 36.9, 129 +/- 53.3, 117 +/- 64.6, 137 +/- 22.6 in Groups 1, 2, 3, and 4, respectively), in the time to drink oral fluids (139 +/- 31.6, 136 +/- 53.8, 123 +/- 65.0, 142 +/- 29.4 min, respectively), or in the incidence of postoperative vomiting. It is concluded that, although desflurane resulted in the fastest early emergence from anesthesia, it was associated with a greater incidence of postoperative agitation. Sevoflurane resulted in similar emergence and recovery compared with halothane. Desflurane and sevoflurane did not result in faster discharge times than halothane in this patient population.

Spinal anaesthesia is widely used for lower limb and lower abdominal surgeries. It has been the mainstay for regional anaesthesia in developing countries, especially in India. Bupivacaine is being extensively used and produces an adequate sensory and motor blockade.However, it has its own disadvantages and side-effects such as cardiac and central nervous system toxicity. Newer longacting local anaesthetics (ropivacaine, levobupivacaine) have recently been introduced for clinical use. The claimed benefits of these are reduced cardiac toxicity on overdose and more specific effects on sensory rather than motor nerve fibres. In our study, we compared the efficacy of 22.5 mg (3ml) of 0.75% isobaric ropivacaine with a control group using 15 mg (3ml) of 0.5% hyperbaric bupivacaine. Ropivacaine for intrathecal anaesthesia in the lower abdominal and lower limb surgeries provided an adequate level of block for the surgery with lesser duration of motor blockade with good analgesia and more hem...

The novel coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. The most common symptoms include fever, cough, and shortness of breath (predominantly involving pulmonary function). However, there are lesser-known presentations that affect other systems too. Vascular complications have been reported in the literature focusing on venous thrombosis, which appears to be more common than arterial thrombosis. Among arterial thrombosis, mainly lower limb involvement is reported so far. Here, we report an unusual presentation in COVID-19, which presented with acute abdomen due to superior mesenteric artery thrombosis without respiratory symptoms. We report this case as a varied form of coronavirus complication presentation and highlight the need for eternal vigilance and a reactive approach for early diagnosis.

Background and Aims: General anesthesia is known to elicit stress response during endotracheal intubation, but the equally important period of extubation is usually not addressed. The aim was to compare dexmedetomidine and esmolol for attenuation of extubation response. Materials and Methods: In this prospective randomized double-blind trial, 100 American Society of Anesthesiologists I/II patients between 18 and 60 years of age undergoing abdominal and lower-limb surgeries were randomly allocated into two groups (n = 50 each). Patients in Group D received dexmedetomidine (0.5 μg/kg intravenous [IV] bolus) over 10 min and in Group E received esmolol (1 mg/kg bolus IV) before extubation. Hemodynamic parameters, namely, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), were compared at baseline, 10 min before extubation, at extubation, and at 1, 3, 5, 10, and 15 min thereafter. Data were expressed as mean ± standard deviation and analyzed using Student's unpaired t-test and Chi-square test. P <0.05 was considered statistically significant. Results: Patients in Group D exhibited lower HR, SBP, DBP, and MAP at the time of extubation till 15 min postextubation (P < 0.001) although the difference was clinically insignificant. Incidence of hypotension was similar in both groups (6% vs. 4%). Two patients in Group D developed bradycardia which was successfully treated with injection glycopyrrolate, while none exhibited any complication in Group E. Conclusion: Dexmedetomidine is a better, effective, and safe alternative to esmolol in attenuating stress response during extubation.

Transcatheter valve implantation in patients with aortic stenosis has evolved as an acceptable alternative to surgical aortic valve replacement in a subset of patients at excessively high risk from surgery. The structural valve degeneration (SVD) is a known phenomenon in catheter-based valves too, which was hitherto seen with surgical bioprosthetic valves. Echocardiography plays a pivotal role not only in early detection but also in the management of SVD of Transcatheter valves. The goal of this report is to agglomerate our experience of an unusual case of SVD of a catheter-based valve implanted inside the bioprosthetic aortic and mitral valve apparatus and its management with aortic and mitral valve replacement with mechanical valve prosthesis.

Cor triatriatum is a rare congenital cardiac anomaly. Majority of the cases present in the childhood with an incidence of 0.4%. However, we report a case of cor triatrium sinister with ostium secundum atrial septal defect (ASD) in a 39-year-old female. The intraoperative 3D transesophageal echocardiography (TEE) offers an advantage over 2D TEE in visualizing the interatrial septum and the attachments of the fibromuscular accessory membrane in the left atrium (LA), which could help in surgical decision-making in this patient.

Perioperative management of pulmonary hypertension remains one of the most challenging scenarios during cardiac surgery. It is associated with high morbidity and mortality due to right ventricular failure, arrhythmias, myocardial ischemia, and intractable hypoxia. Therefore, this review article is intended toward the anesthetic considerations in the perioperative period, with particular emphasis on the selection of technique and choice of anesthesia with maintenance, anesthetic drugs, and the recent intraoperative recommendations for prevention and treatment of pulmonary hypertensive crisis.

Background: Off-pump coronary artery bypass surgery (OPCAB) is often complicated by hemodynamic instability, especially in patients with prior left ventricular (LV) dysfunction and appropriate choice of inotrope plays a vital role in perioperative management of these patients. Aim and Objective: To study hemodynamic effects and immediate outcome of prophylactic infusion of levosimendan in patients with the LV dysfunction undergoing OPCAB surgery and whether this strategy helps in successful conduct of OPCAB surgery. Materials and Methods: After Institutional Ethics Committee approval, 60 patients posted for elective OPCAB surgery were randomly divided into two groups (n = 30 each). Patients with the LV ejection fraction <30% were included. Study group was started on injection levosimendan (@ 0.1 μg/kg/min) in the previous night before surgery and continued for 24 h including intraoperative period. Hemodynamic monitoring included heart rate, invasive blood pressure, cardiac index ...

Background: Acute pain in the perioperative setting is detrimental to post operative outcome and adequate analgesia leads to better outcome. It increases sympathetic response of the body with subsequent rise in oxygen consumption of body, risk of deep vein thrombosis due to immobility and consequent pulmonary embolism. Methods: Sixty ASA I/II patients between 18- 65 years undergoing laparoscopic cholecystectomy and appendicectomy were included and randomly divided into 2 groups. ASA III/IV patients, previous opioid and alpha 2 agonist treatment and patients requiring extensive surgical dissection were excluded. Group D received IV Dexmedetomidine 1 \(\mu\)g/kg over 10 min followed by 0.2-0.7 \(\mu\)g /kg/hr and Group P received IV Paracetamol 15 mg/kg prior to extubation. Patients were monitored for hemodynamics and VAS score was assessed after extubation till 24 hours. Rescue analgesia (IV tramadol 1 mg/kg) was given and the time interval till the requirement of first dose of rescu...

Background: Central venous and pulmonary artery catheter are integral part of hemodynamic monitoring during off pump coronary artery bypass grafting surgery. Methods: In this prospective randomized trial, sixty patients were divided equally into two groups, to receive either central venous or pulmonary artery catheter after induction of anesthesia with high dose of opioid and Inj pancuronium. Patients between 35-65 years with ejection fraction 40-60% undergoing elective off pump coronary artery bypass surgery were included while those with left ventricular dysfunction were excluded. All patients were operated by same team of surgeons. Systolic blood pressure (SBP) and/or mean arterial pressure (MAP) was kept above 90 and 60 mm Hg respectively throughout perioperative period by fluid volume expansion and inotropic support. Nitroglycerine was used for blood pressure control and coronary vasodilation. Both groups were compared with respect to intervention requiring inotropes and its du...

Dexmedetomidine is a novel drug which is a selective a2-adrenoceptor agonist. It has unique properties of producing sedation, anxiolysis, amnesia and analgesia but at the same time without respiratory depression. It provides a unique “conscious sedation” (patients appear asleep, but are readily roused), analgesia, without respiratory depression. It decreases central nervous system (CNS) sympathetic outflow in a dose dependent manner and has analgesic effects best described as opioid-sparing. There is the increasing evidence of its organ protective effects against ischemic and hypoxic injury, including cardioprotection, neuroprotection and renoprotection. This presentation is intended to highlight special situations in cardiac anesthesia (especially paediatric) where dexmedetomidine plays a crucial role. Biography Manjula Sarkar is the Professor and Head, Department of cardiothoracic and vascular anaesthesia in Seth G.S. Medical College and King Edward Memorial Hospital, Mumbai, Indi...

The aim of this study is to determine safety and feasibility of conscious sedation using dexmedetomidine for transcatheter atrial septal defect (ASD) device closure. A retrospective institutional review of transcatheter ASD device closure without endotracheal intubation over 18 months. The protocol included topical oropharyngeal anesthesia using lignocaine followed by dexmedetomidine bolus 1 μg/kg intravenously over 10 min and maintenance dose 0.2-0.7 μg/kg/h. Ramsay sedation score 2-3 was maintained. Patients were analyzed regarding demographic profile, device size, procedure time, anesthesia time, recovery time, hospital stay, and any hemodynamic or procedural complications. A total of 43 patients with mean age 31.56 ± 13.74 years (range: 12-56 years) were analyzed. Mean anesthesia duration was 71.75 + 21.08 min. Mean recovery time was 7.6 ± 3.01 min. 16 females and one male patient required additional propofol with a mean dose of 30.8 ± 10.49 mg. No hemodynamic instability was no...

Electrical cardioversion is a short painful procedure to regain normal sinus rhythm requiring anaesthesia for haemodynamic stability, sedation, analgesia and early recovery. To compare propofol and etomidate as sedatives during cardioversion. Single centred, prospective and randomized single blind study comprising 60 patients. Patients more than 18 years, American Society of Anesthesiologists I/II/III grades undergoing elective cardioversion, randomly divided to receive propofol 1 mg/kg intravenous (IV) bolus followed by 0.5 mg/kg (Group P, n = 30) or etomidate (Group E, n = 30) 0.1 mg/kg followed by 0.05 mg/kg. All patients received IV fentanyl (1 μg/kg) before procedure. Heart rate, blood pressure (BP) (systolic BP [SBP], diastolic BP [DBP], mean arterial pressure), respiratory rate, Aldrete recovery score (ARS) and Ramsay sedation score (RSS) were assessed at 1, 2, 5, 10, 15, 20 and 30 min post cardioversion. Incidence of hypotension, respiratory depression and side effects were compared. Student's unpaired t-test, Chi-square test and Mann-Whitney test. P < 0.05 was taken as significant. Group P showed significant fall in SBP, DBP, and mean BP at 2 min after cardioversion. Hypotension (33.3% Group P vs. 16.65% Group E) occurred more with propofol (P < 0.05). Group E showed better ARS at 1, 2, 5, 10, 15 and 20 min. Time required to attain RSS = 2 (659.1 s Group P and 435.7 s Group E) indicated longer recovery with propofol. Left atrial size (35.5-42.5 mm) did not affect success rate of cardioversion (80% Group P vs. 83.3% Group E). Incidence of myoclonus (Group E 26.67% vs. Group P 0%) showed significant difference. Etomidate/fentanyl is superior over propofol/fentanyl during cardioversion for quick recovery and haemodynamic stability.