Anaesthesia
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Item Anaesthetic requirements in patients with medically refractory seizures undergoing neurosurgery(SCTIMST, 2020-12-31) Nagmoti Shilpa VikasraoItem Assessment of myocardial deformation during off pump CABG (OPCABG) using speckle tracking echocardiography(SCTIMST, 2018-12) Garre, SandeepItem Item Bedside Chest Ultrasound in post operative pediatric Cardiac Surgery patients: Comparison with bedside chest radiography.(2019-12-31) Don Jose PalamattamTraditionally, chest imaging in post operative cardiac surgical patients, is performed using bedside chest radiography (CXR). It is considered as standard of care to evaluate intra-thoracic structures including heart, lung, mediastinum and their abnormalities. CXR also evaluates position of chest tubes, mediastinal tubes, central venous lines, pulmonary artery catheters, endotracheal tubes and enteral feeding tube [1]. Respiratory complication is one of the major causes of morbidity and death in cardiac post operative patients in adult and pediatric population. Whenever there is a suspicion of intra thoracic pathology, including improper position of tubes and catheters, the need for repeated bedside CXR and thus subsequent unavoidable radiation exposure is inevitable. Other factors leading to the need for repetition of bedside CXR are suboptimal X-ray films, improper positioning of patient and poor correlation with CT scan [2]. Each bed side CXR exposes a patient to 0.02 milli-sieverts of radiation [3]. Though it looks invariably small, repeated CXRs exposes patient to increasing amounts of radiation. Paediatric age group especially neonates , have greater areas of exposure, due to small body surface area and are thus sensitive to hazardous effects of ionizing radiation. The threat of developing immune dysfunction, cataract, cognitive decline and malignancy in later part of life is a possibility [4]. Therefore, effort should be made to minimize radiation exposure whenever possible [5]. Chest ultrasound (CUS) is a fast, repeatable and radiation free methodology. 2 It is simple to use and requires a limited period of training [6]. It allows for bedside detection of primary pulmonary pathologies [7] such as pleural effusion, pneumothorax, lung atelectasis, or secondary pulmonary pathologies due to cardiac causes (interstitial pulmonary oedema, basal atelectasis) and conditions such as diaphragmatic palsy, subcutaneous emphysema, pericardial effusion, cardiac tamponade and endobronchial intubation [8]. Examination can be done alone or in combination with echocardiography and intravascular volume assessment, thus reducing cost and time. Diaphragmatic dysfunction, due to phrenic nerve injury, is a complication in postoperative cardiac surgery patients, with an incidence between 0.3% - 20% [9]. Most phrenic nerve injuries are due to transient neuroapraxia of the nerve, secondary to traction, local application of cold solutions, or accidental injury [10]. Rarely, it is caused by direct transection of the phrenic nerve. Diaphragmatic dysfunction impedes normal lung expansion during inspiration [9] and weaning from mechanical ventilation becomes difficult. It is associated with prolonged ventilatory support, intensive care stay, increased risk of nosocomial infections, and an overall morbidity and death [11]. Chest fluoroscopy is the gold standard for diagnosis of diaphragmatic dysfunction. But it is associated with shifting of critically ill children to radiology suite and exposure to higher ionizing radiation. Other modalities include phrenic nerve conduction studies and CUS. CUS being a rapid and easily available technique at the bedside, allows for early diagnosis of abnormal diaphragmatic motion [12]. 3 The use of CUS in the post operative adult cardiac patients is gaining popularity [6]. However, there is little data available concerning the use of CUS in the post operative cardiac pediatric and neonatal populations [13]. To address the above issue, we intend to study the degree of agreement between CUS and CXR; to compare the diagnostic performance of bedside chest ultrasound (CUS) with bedside chest radiography (CXR), for the detection of abnormalities of thorax including abnormal diaphragmatic motion, in postoperative pediatric cardiac surgical patients. We also intend to compare the therapeutic interventions done on basis of CUS and CXR derived information in the postoperative setting.Item Item Comparison of Effects of Propofol and Dexmedetomidine on Motor Evoked Potentials in Neurosurgery: A Prospective Randomised Single Blinded Interventional Study(SCTIMST, 2019-12) Soniya BiswasIntraoperative neurophysiological monitoring (IONM) is often used in various intracranial and spine procedures to prevent damage to eloquent areas, cranial nerves or motor or sensory tracts. Motor evoked potential (MEP) monitoring is invariably an essential tool in the armamentarium of the operating surgeons to avoid injury to the motor tract in various intracranial and spine surgeries. (1) Transcranial motor evoked potential (TcMEP) monitoring is stimulation of the motor cortex through the skull and eliciting compound muscle action potentials (CMAP) from the peripheral muscles to test the intactness of the motor pyramidal pathway. (1) TcMEP is being used in surgeries for monitoring and mapping of the motor pathways. It is used in the mapping of the motor cortex in resection of tumours or arteriovenous malformations located near the motor cortex or in epilepsy surgeries. It is also used in the subcortical mapping of corticospinal tract. It is also used in brainstem surgeries and in Chiari malformation. It is also used in vascular surgeries like carotid endarterectomy, reconstructive surgeries of the neck, aneurysms of the aortic arch and of thoracoabdominal aorta or intracerebral aneurysms of middle or anterior cerebral arteries. It is very commonly used in spinal surgeries for extradural or intradural (extramedullary or intramedullary) tumour resection, embolization of arteriovenous malformations and in deformity corrective surgeries like scoliosis and spondylolisthesis. (2) Intraoperatively, there are many factors other than surgical manipulation that can affect the quality of the CMAP like temperature, blood pressure, partial pressure of expiredcarbon dioxide, oxygen, etc. These factors need to be optimized for correct interpretation of the MEPs. (2) The anaesthetic agents can affect the quality of MEP intraoperatively as they inhibit synaptic transmission. Muscle relaxants antagonize the transmission of signals across the neuromuscular junction. Inhalational agents suppress the CMAP and should be used at a lower minimum alveolar concentration (MAC). Opioids seem to have very little effect on CMAP. Intravenous anaesthetics suppress MEP lesser than inhalational agents, so total intravenous anaesthesia (TIVA) or combination of intravenous with minimal inhalational anaesthetic supplementation is used when MEPs are monitored. (3) TIVA with propofol and opioid is most commonly used for MEP monitoring. (4) As propofol gets rapidly metabolised, its sedative effects and effects on MEP can be adjusted quickly. But MEP can get depressed at high doses required to maintain surgical depth, hence, adjuvant agents that maintain anaesthetic depth without affecting the MEP are often required. (5) Dexmedetomidine is a selective alpha-2 agonist. It causes sedation, analgesia, sympatholysis and minimal respiratory depression. (6) Its addition to the anaesthetic regimen can reduce hypnotic requirement, especially propofol. Dexmedetomidine has invariably been used as an adjuvant to various anaesthetic agents and has been found to have minimal affect on the MEP when combined with other agents. (7) It has found widespread acceptance in neuroanaesthesia because of its favourable recovery characteristics and absence of significant impact on cerebral blood flow and intracranial pressure.Item Comparison of Four Routes of Central Vein Cannulation Using Real Time Ultrasound Guidance in Cardiovascular Surgical Patients –A Prospective Randomised Study(SCTIMST, 2016-12) Deepak Mathew, GregoryItem Comparison of hemodynamic parameters measured by thoracic electrical bioreactance and 3 d transesophageal echocardiography in adult cardiac surgery patients(SCTIMST, 2020-12-31) Nithiyanandhan P.Item