Biomedical subjects
Publications and source records attributed to S K Pandit.
A neonate with Morgagni hernia and ventricular septal defect is reported. Presentation of Morgagni hernia in neonates is rare, but when it does, it is associated with other congenital anomalies.
Ketorolac tromethamine (Toradol) is a parenteral, nonsteroidal antiinflammatory drug that is being extensively used to provide postoperative analgesia. This study evaluated whether intraoperative ketorolac would act synergistically with fentanyl to decrease postoperative analgesic requirements in outpatients undergoing gynecologic procedures. The patients studied were adult ASA physical status I or II females scheduled for diagnostic laparoscopy (DL) (n = 80) or laparoscopic tubal ligation (TL) (n = 46). Each patient received fentanyl 2 micrograms/kg intravenously (i.v.) before induction, followed by a standardized propofol anesthetic and 2 mL of saline or ketorolac 60 mg i.v. in a randomized double-blind fashion 30 min before the anticipated end of the operative procedure. Patients were assessed for postoperative pain via a 10-cm visual analog scale (VAS) (0 = no pain; 10 = severe pain) before analgesic treatment in the postanesthesia care unit (PACU). Severe postoperative pain (VAS or 5 or more) was treated with incremental doses of fentanyl, 25-50 micrograms i.v. by a blinded PACU nurse. Ibuprofen or acetaminophen with codeine was administered for pain control once the patient tolerated oral medications. This study showed that intraoperative ketorolac (60 mg i.v.) with fentanyl (2 micrograms/kg i.v.) administered at the induction of anesthesia resulted in significant opioid sparing and a diminution in pain in the DL sample but not in the TL sample. The analgesic regimen was also associated with a lower incidence of nausea and vomiting and resulted in earlier discharge, which was not seen after TL. These results demonstrate that pain after TL is far greater than that after DL, which suggests that these procedures should be considered separately when designing analgesic regimens.
Several papers in the 1980s questioned the wisdom of withholding clear liquids for more than 3 h before elective surgery. Furthermore, recent papers have suggested relaxing the current NPO after midnight (Latin: Nulla per os; or "nothing by mouth") practice in children and adults. To see whether the policy and practice regarding NPO status before elective surgery have changed in the United States, we performed a national survey. In November 1992, 300 questionnaires were mailed to the chairpersons of 114 university anesthesiology programs and the medical directors of 186 randomly selected, free-standing ambulatory surgery centers. Seventeen simple questions were asked regarding their NPO policy and practice guidelines before elective operations. Replies were tabulated, and the data were descriptively analyzed via frequency distribution. We received 191 replies, 85 from the university programs and 106 from the free-standing units (75% and 57% response rates, respectively) from all six time zones of the United States. Fifty-seven percent of the responders stated that they had revised their NPO policy during the last 3 yr, whereas 39% reported that they had not changed their NPO policy. One hundred percent of the respondents who allowed clear liquids considered water to be acceptable for adults, whereas 94% considered water acceptable in the pediatric population. Eighty-one percent of the responders denied the use of routine prophylaxis for acid aspiration. None of the responders reported an adverse outcome which could be attributable to the recent change in the NPO guidelines. On a related question, 16% of all the respondents stated that they would cancel the operation if a patient arrived for an elective outpatient surgical procedure after consuming coffee with cream 2 h before operation. In conclusion, our survey revealed that 69% of anesthesiologists in the United States have either changed their NPO policy or are flexible in their practice in allowing clear liquids before elective operation in children and 41% have done so for adult patients. The most frequently allowed clear liquids in the adult and pediatric population were water and apple juice. None of the respondents reported any medical adverse event associated with the institution of a flexible NPO policy.
We report a patient with isolated levocardia without cardiac or splenic defects associated with duodenal membrane.
A rare association of pyloric membrane, Meckel's diverticulum and pelvi-ureteric junction obstruction in a 3-year-old boy is reported.
General anesthesia is the most common form of anesthetic management for ambulatory surgery. Patients, in general, prefer general anesthesia because it is less anxiety provoking. During the last decade, the availability of several short-acting agents with high clearance has made general anesthetic techniques much safer and more predictable for outpatients. Besides, general anesthesia today is associated with a quick and full recovery with minimal postoperative side effects. Proper preanesthetic psychological and, when necessary, pharmacological preparation as well as proper selection of anesthetic agents are the keys to the success of general anesthetic technique for ambulatory surgery. Although both TIVA and total inhalation anesthetic techniques have their advocates, balanced anesthesia is most popular. The introduction of several new agents (e.g., propofol, desflurane, vecuronium, atracurium, mivacurium, rocuronium, alfentanil, ondansetron, ketorolac) has made ambulatory general anesthesia less challenging and more interesting. In the future, the new anesthetic sevoflurane, and the new opioid remifentanil, may prove useful for ambulatory anesthesia. The LMA has all but revolutionized airway management during general anesthesia for ambulatory surgery.
A clinical and radiological study of 80 postburn patients to determine the extent of bone and joint changes is presented. The group comprised 38 males and 42 females, with ages ranging from 2 to 60 years. The time since burning ranged from 6 to 12 months in 40, from 1 to 5 years in 24 and over 5 years in 16 patients. Clinically bone and adjoining tissue involvement were seen in 32 patients (40 per cent), while radiological changes were seen in 49 (61.25 per cent). Radiological changes noted included osteoporosis 56.25 per cent, stunted growth (phalanges and limbs) 27.5 per cent, osteomyelitis 2.5 per cent, partial resorption of terminal phalanges and ankylosis 1.25 per cent each. Periarticular, pericapsular and tendon calcification were each seen in 1.25 per cent of the patients. Bone and joint changes were encountered only in major burns, and these could be minimized by proper early surgical care and long-term rehabilitation.
This study compares the induction, hemodynamic, and recovery characteristics of a general anesthetic with desflurane to one with propofol. Sixty outpatients presenting for orthopedic surgery received either a propofol induction of anesthesia followed by desflurane and nitrous oxide (Group 1), a propofol induction followed by propofol infusion and nitrous oxide (Group 2), a desflurane and nitrous oxide induction and maintenance (Group 3), or a desflurane induction and maintenance (Group 4). The quality of induction was inferior in Groups 3 and 4 with more breath-holding and excitation than in Groups 1 and 2. However, there was a more rapid emergence in Group 4 patients than any of the other groups. Group 4 patients were able to say their names (5.6 +/- 2.0 min vs 10.3 +/- 3.3 min, 8.6 +/- 3.1 min, and 9.3 +/- 1.5 min for Groups 1, 2, and 3, respectively) sooner after the discontinuation of anesthesia. Nonetheless, intermediate recovery was similar in Groups 2 and 4 being numerically but not statistically more rapid than in Groups 1 and 3. This pattern of intermediate recovery was also demonstrated by psychomotor function test results. Although there was no difference between the groups in postoperative narcotic requirement, more patients in Group 3 vomited (50%) than in either Group 2 (0%) or Group 4 (12.5%). Hemodynamically, the anesthetics were very similar. Although desflurane was a difficult drug to use for induction of anesthesia, this study demonstrates that desflurane is a suitable maintenance anesthetic for ambulatory surgery because it provides a rapid awakening and an intermediate recovery similar to propofol.
A study to assess the reliability of clinical symptoms and signs in 50 patients with a presumptive diagnosis of acute appendicitis is presented. The male to female ratio was 3: 2, with age ranging from 2 to 15 years. Abdominal pain was present in 42; tenderness was localized in 35, generalized in 11 and diffuse in 4 patients. Total leucocyte count was above 11,000/cu mm in 31, below 11,000/cu mm in 17 and above 18,000/cu mm in 2. Of the 48 operated patients, 8 had normal appendices and the diagnosis in them was Meckel's diverticulitis 3, ruptured ovarian follicle 2, mesenteric adenitis 2, and salpingo-oophoritis 1. Abdominal pain and right iliac fossa tenderness with contributory investigations are the most reliable indicators of acute appendicitis with a false positive rate of 16.66% only.
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We estimated the potency of vecuronium and measured the onset and duration of its action during total intravenous anesthesia with propofol to examine the possibility of any interaction between these two drugs. Propofol infusion was administered according to a three-step dosage scheme, and neuromuscular block was monitored by measuring the force of contraction of the adductor pollicis muscle after single-twitch stimulation of the ulnar nerve at 0.1 Hz. A control group of patients were similarly studied during anesthesia with thiopental, nitrous oxide, oxygen, and fentanyl. The ED50 and ED95 (dose required to produce a 50% and 95% depression of twitch tension, respectively) of vecuronium in patients given total intravenous anesthesia (n = 24) were 24 (22-27, 95% confidence limits) and 41 (37-48, 95% confidence limits) micrograms/kg, respectively, and in the control group (n = 24), 20 (17-24) and 39 (34-37) micrograms/kg, respectively. The onset of action of an 80-micrograms/kg dose (2 x ED95) of vecuronium was 3.6 +/- 1.2 and 4.1 +/- 1.7 min (mean +/- SD), in the propofol (n = 10) and control (n = 10) groups, respectively. The respective times to recovery of the twitch height to 25% of control and the recovery indices (25%-75% recovery of twitch height) in the propofol versus control groups were 28.3 +/- 6.6 and 28.0 +/- 1.7 min and 13.3 +/- 6.8 and 15.4 +/- 11.9 min, respectively. There were no significant differences in any of the measured variables between the propofol and control groups, indicating the lack of any interaction between propofol and vecuronium.
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One hundred adult female patients scheduled for outpatient laparoscopic procedures were studied. Each patient received intravenous premedication about 30 min before induction of anaesthesia. The premedications were given in a double-blind random order and were either a placebo, morphine (0.04 mg/kg), meperidine (0.35 mg/kg), fentanyl (0.75 microgram/kg) or sufentanil (0.15 microgram/kg). All patients received a standard anaesthetic regimen. Transient light-headedness was common following narcotic injections. Overall, sufentanil was superior to the placebo and to other narcotics in its ability to reduce preoperative anxiety and to provide more satisfactory induction, maintenance and recovery from anaesthesia. The incidence of postoperative nausea, vomiting and other side effects was not higher and discharge times were not longer after sufentanil compared to the placebo group. Complete recovery as assessed by telephone interview 24-48 h after the operation revealed no difference between the sufentanil and the other groups. The results of this study indicate that intravenous short-acting narcotics like fentanyl or sufentanil should be considered as an alternative premedicant for anxious patients who are scheduled for outpatient surgery.
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Our studies on the effects of subhypnotic doses of midazolam in healthy adult volunteers have been extended with special emphasis on clinical electrophysiological endpoints of sedation and attention coupled with various tests of memory. We measured the many components of the P300 event-related brain potential to infrequent (rare) tones. Midazolam HCl was given in a dose of .02 mg/kg i.v. three times at approximately 15-minute intervals after obtaining baseline electrophysiological recordings and memory test results. Marked individual variation was observed with these small doses of midazolam. Some subjects were markedly sedated, whereas others showed relatively little sedation. Electroencephalogram (EEG) beta activity increased while alpha activity decreased following midazolam. Even though the subjects given midazolam were awake, there was a striking attention deficit that correlated well with the accuracy of counting rare tones and the alterations in various components of the late auditory event-related brain potential.
Midazolam can be used to achieve anxiolysis, to provide conscious sedation with anterograde amnesia during operations performed under local or regional anesthesia, to induce general anesthesia, and as part of a balanced anesthetic. Understanding the pharmacologic properties and potential adverse side effects of any drug is necessary in order to dose and monitor patients effectively. When used with vigilance, appropriate patient monitoring, and slow, careful titration to desired effect, midazolam is an extremely useful and safe medication for both inpatients and outpatients.