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   Table of Contents - Current issue
Coverpage
October-December 2022
Volume 12 | Issue 4
Page Nos. 116-160

Online since Sunday, April 17, 2022

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Looking for more than hot air: how experimental design can enhance clinical evidence for hyperbaric oxygen therapy p. 116
Adam T Biggs, Lanny F Littlejohn
DOI:10.4103/2045-9912.337992  PMID:35435421
Hyperbaric oxygen therapy is emerging as a potential treatment for critical medical and psychological issues, including mild traumatic brain injury, traumatic brain injury, and post-traumatic stress disorder. Based on the promising results from numerous case studies, randomized clinical trials generated conflicting interpretations despite frequent improvements in patient symptoms. The primary debate concerns whether the therapeutic benefits could be attributed to placebo effects or sham conditions that actually induce a therapeutic state. In part, the contention has been exacerbated by experimental designs which could not properly account for extraneous variables, such as the potential for differing patient expectations to influence the outcome. The current discussion addresses five methodological challenges that complicate any determination of clinical significance due to experimental design. These challenges include: 1) not properly addressing or controlling patient expectations prior to the experimental sessions; 2) the challenge of experimental masking in clinical designs that require pressurized environments; 3) patient subjectivity in the primary dependent variables; 4) potential fluidity in patient symptoms or data, such as regression to the mean; and 5) the potential for nocebo effects to exaggerate treatment benefits by lowering performance expectations during pre-treatment assessments. Each factor provides an influential means by which placebo effects could complicate results and prevent the combined data from reaching a threshold of clinical significance. The discussion concludes with methodological best practices with which future research could minimize placebo effects and produce more conclusive results.
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Devil or angel: two roles of carbon monoxide in stroke p. 125
Bing Li, Jian Xiong, Hui-Xiang Liu, Di Li, Gang Chen
DOI:10.4103/2045-9912.337993  PMID:35435422
Stroke is one of the most important acute diseases that endanger human health and result in death, including acute cerebral hemorrhage and acute cerebral ischemia. Acute onset is its most prominent feature. Carbon monoxide (CO) is a colorless and odorless gas existing at room temperature. It is not only a common air pollutant, but also has been found to be closely related to stroke. A large amount of exogenous CO has an important impact on the incidence and prognosis of stroke, while endogenous CO as a gas signal also has an important impact on neuroprotection after stroke. Both low-dose CO inhalation and CO-releasing molecule-3 (a molecule that emits CO) treatment have shown the benefits of stroke, and perhaps the role of CO in stroke is one of the key areas for future research.
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RESEARCH ARTICLES Top

Anesthetic gas consumption with target-controlled administration versus a semi-closed circle system with automatic end-tidal concentration control in an artificial lung model p. 131
Martin Bellgardt, Vladimir Vinnikov, Adrian Iustin Georgevici, Livia Procopiuc, Thomas Peter Weber, Andreas Meiser, Jennifer Herzog-Niescery, Dominik Drees
DOI:10.4103/2045-9912.337991  PMID:35435423
The use of volatile anesthetics as sedatives in the intensive care unit is relevant to the patient’s outcome. We compared anesthetic gas consumption of the conventional semi-closed Aisys CSTM with the MIRUSTM system, which is the first anesthetic gas reflector system that can administer desflurane in addition to isoflurane and sevoflurane. We connected an artificial lung model to either a MIRUSTM system and a Puritan BennettTM 840 ventilator or an Aisys CSTM anesthesia machine. We found that consumption of 0.5% isoflurane, which corresponds to the target concentration 0.5 MAC, was averaged to 2 mL/h in the MIRUSTM system, which is identical to the Aisys CSTM at a fresh gas flow (FGF) of 1.0 L/min. MIRUSTM consumption of 1% sevoflurane was averaged to 10 mL/h, which corresponds to 8.4 mL/h at FGF 2.5 L/min. The MIRUSTM system consumed 3% or 4% desflurane at an average of 13.0 mL/h or 21.3 mL/h, which is between the consumption at 1.0 L/min and 2.5 L/min FGF. Thus, the MIRUSTM system can effectively deliver volatile anesthetics in clinically relevant concentrations in a similar rate as a conventional circular breathing system at FGFs between 1.0 L/min and 2.5 L/min.
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Prospective randomized double-blind study to evaluate propofol and combination of propofol and sevoflurane as maintenance agents in reducing postoperative nausea and vomiting in female patients undergoing laparoscopic surgery p. 137
Teena Bansal, Suresh Singhal, Khushboo Kundu
DOI:10.4103/2045-9912.337994  PMID:35435424
Prevention and management of postoperative nausea and vomiting (PONV) is a fundamental part of anesthesia. Using sevoflurane and propofol in combination for maintenance of anesthesia has been found to reduce PONV compared to sevoflurane alone. However, there are limited studies comparing propofol with a combination of propofol and sevoflurane for the incidence of PONV after laparoscopic surgery. The prospective, randomized, double-blind study was planned to compare propofol and combination of propofol and sevoflurane as maintenance agents for the incidence of PONV. Seventy female patients of 18–60 years, of American Society of Anesthesiologists I or II, undergoing laparoscopic surgery were included. Propofol group (n = 35) included induction with propofol and maintenance with propofol infusion, and propofol + sevoflurane group (n = 35) included induction with propofol and maintenance with a combination of propofol infusion and sevoflurane inhalation. The objectives were to find the incidence of PONV and requirement of rescue antiemetic. In the propofol group, 11 patients (33%) experienced PONV and in the propofol + sevoflurane group, PONV was experienced by 12 patients (38.7%) [0.65]. In the propofol group, 11 patients required ondansetron and out of these 11 patients, 2 patients required metoclopramide. In the propofol + sevoflurane group, Ondansetron was required by 12 patients and 3 patients out of these 12 patients required metoclopramide. In the present study, the incidence of PONV was found to be similar in both groups. So, it can be suggested to add sevoflurane in smaller doses to infusion of propofol for maintenance of anesthesia.
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Preemptive low-dose intravenous ketamine in the management of acute and chronic postoperative pain following laparoscopic cholecystectomy: a prospective randomized control study p. 141
Shruti Jain, Nazia Nazir, Saurav Mitra Mustafi
DOI:10.4103/2045-9912.337995  PMID:35435425
Preemptive analgesia with intravenous ketamine has been utilized as a part of multi-modal analgesia for acute postoperative pain following laparoscopic cholecystectomy with mixed outcomes. We tested the effectiveness of low-dose ketamine for acute and chronic postoperative pain after laparoscopic cholecystectomy in a randomized controlled experiment. The study involved 50 individuals who had a laparoscopic cholecystectomy under general anesthesia. All the patients were separated into two equal groups. The ketamine and control groups were given 0.5 mg/kg ketamine and 2 mL of normal saline, respectively, at 15 minutes before incision. Patients in the ketamine group had a significantly lower numeric pain rating scale score at 0 minutes than those in the control group. The numeric pain rating scale score of the ketamine group was considerably greater than the control group after a half-hour interval. At other time periods, there was no significant difference in numeric pain rating scale scores between the two groups. The ketamine group had a greater duration of analgesia and sedation score than the control group. The cumulative tramadol demand at 24 hours and the incidence of chronic pain did not differ significantly across the groups. Substantial analgesic effect of intravenous ketamine lasted only up to 30 min postoperatively. There was no discernible effect in terms of chronic pain prevention.
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Comparison of dexmedetomidine and remifentanil infusion in geriatric patients undergoing outpatient cataract surgery: a prospective, randomized, and blinded study p. 146
Cem Kaya, Nalan Ornek Celebi, Sehend Debbag, Ozgur Canbay, Ozkan Onal
DOI:10.4103/2045-9912.337996  PMID:35435426
Dexmedetomidine is an α2 agonist and remifentanil is a short-acting μ opioid agonist. We aimed to compare the dexmedetomidine and remifentanil infusions used for conscious sedation in geriatric patients undergoing outpatient cataract surgery in terms of sedation quality, side effects, and surgeon satisfaction. Eighty patients were allocated into two groups as per the administration of dexmedetomidine (dexmedetomidine group) and remifentanil (remifentanil group) infusion in this randomized, prospective, double-blinded study. In dexmedetomidine group (n = 40), after a loading of 1 μg/kg dexmedetomidine in 10 minutes, 0.4 μg/kg/h infusion was administered. In the remifentanil group (n = 40), remifentanil at a dose of 0.05 μg/kg was administered for 10 minutes, and then 0.05 μg/kg/min infusion was continued. Observer Assessment Warning/Sedation Scale values evaluating sedation quality were lower in the dexmedetomidine group than in the remifentanil group, although it was not statistically significant (P > 0.05). Bispectral Index values evaluating sedation quality were lower in the dexmedetomidine group according to the remifentanil group (P < 0.05). The dexmedetomidine group had lower Verbal Rating Scale and Visual Analogue Scale scores evaluating pain intensity compared with the remifentanil group (P < 0.05). The nausea Visual Analogue Scale values evaluating the severity of postoperative nausea in the dexmedetomidine group were lower than those in the remifentanil group (P < 0.05). The surgeon satisfaction was found to be greater in the dexmedetomidine group compared with the remifentanil group (P = 0.015). In geriatric patients, the targeted sedation and analgesia levels were achieved more easily with dexmedetomidine infusion, without hemodynamic and respiratory side effects, compared to remifentanil infusion.
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Hyperoxia and the cardiovascular system: experiences with hyperbaric oxygen therapy p. 153
Jochen D Schipke, Thomas Muth, Clark Pepper, Johannes Schneppendahl, Martin Hoffmanns, Sven Dreyer
DOI:10.4103/2045-9912.337997  PMID:35435427
Hyperoxia has been described to induce bradycardia by direct stimulation of the parasympathetic nervous system. Also, hyperoxia has been found to increase blood pressure by an elevation of vascular resistance. However, the latter effect itself would induce bradycardia by baroreceptor stimulation. This single-arm monocentric retrospective study aims to evaluate the correlation between these effects by investigating the relation between oxygen (O2) administration and heart rate over time. Data were collected from 23 patients without cardiovascular problems undergoing hyperbaric oxygen therapy (2.4 bar) retrospectively. During single oxygen bouts, transcutaneously measured partial pressure of O2 was increased. During this surge of oxygen pressure, the arterial blood pressure was increased while the heart rate was decreased. Respiration rate was maintained independently from breathing 100% O2 or air. During single oxygen bouts, the half-life of transcutaneously measured partial pressure of O2 was 5.4 ± 2.1 mmHg/s, and the half-life of heart rate was 0.45 ± 0.19 beats/min. It has been shown that hyperbaric oxygen therapy increases the transcutaneously measured partial pressure of O2. This increase was rather fast, followed by a rather slow decrease in HR. This finding does not support direct vagal activation. Heart rate is not decreased due to a direct vagal activation during hyperbaric oxygen therapy. Our single-arm, retrospective study has additionally confirmed that oxidative stress injures the endothelium, and the reduced endothelial-derived vasodilators cause vasoconstriction. As a consequence, blood pressure increases, and heart rate is then further decreased via the baroreceptor reflex.
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CASE REPORT Top

A case report of retrograde intubation as rescue procedure in unanticipated difficult airway: an old technique still relevant in low resource settings p. 158
Tanmay Tiwari, Bhawana Sharma, Sachin Kumar Rajput
DOI:10.4103/2045-9912.337998  PMID:35435428
In cases with an unanticipated difficult airway, retrograde intubation can be used as an alternative procedure for airway management when a fiber optic bronchoscope is unavailable. We here report a case of successful management of an unanticipated difficult airway following a failed intubation in a 34-year-old 54 kg male patient with carcinoma lateral border of tongue using retrograde intubation guided technique. Maintaining oxygenation and minimizing airway trauma should be the priority following a failed intubation. Decisions seeking alternative techniques following failed intubation are easy, if valid and applicable techniques (as per anesthesiologist’s skills and available resources) are discussed before induction of anesthesia.
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