NepMed Repository :: Browsing by Author "Bhattarai, B"

Browsing by Author "Bhattarai, B"

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A comparative study of early vs. delayed laparoscopic cholecystectomy in acute cholecystitis
(Kathmandu University, 2009) Yadav, RP; Adhikary, S; Agrawal, CS; Bhattarai, B; Gupta, RK; Ghimire, A
NA
Analgesia before Performing Subarachnoid Block in the Sitting Position in Patients with Proximal Femoral Fracture: A Comparison between Fascia Iliaca Block and Femoral Nerve Block
(Kathmandu University, 2015) Ghimire, A; Bhattarai, B; Koirala, S; Subedi, A
ABSTRACT Background Positioning for subarachnoid block (SAB) in patients with femoral fracture is painful and may remain suboptimal requiring use of large doses of opioids. These patients generally being elderly with multiple comorbidities and frailty are likely to have many undesirable effects of opioids including respiratory depression and confusion. Objective The objective was to compare the feasibility and effectiveness of fascia iliaca compartment block (FICB) and femoral nerve block (FNB) in reducing pain associated with positioning for subarachnoid block in patients undergoing proximal femoral fracture fixation procedures. Method Group FICB patients (n=15) received fascia iliaca block with 30 ml of 1.5% lignocaine with adrenaline and group FNB patients (n=15) received femoral nerve block with 15 ml of 1.5% lignocaine with adrenaline. After the study blocks, patients were kept on supine position for at least 20 minutes before shifting them to the operation theatre. Pain was assessed by using visual analog scale values before the block and during the position for subarachnoid block. Time to perform subarachnoid block, quality of positioning and acceptance was recorded. Result Visual analog scale values during positioning for SAB were lower in FIB group than in FNB (1.0±1.1 versus 2.1±0.8; P<0.05). Time to perform SAB was shorter in FIB than in FNB (109.6±28.2 seconds versus 134.8±31.9 seconds; P<0.05). Quality of patient positioning for SAB was comparable between the groups. Patient acceptance was less in group FNB (P<0.05). Conclusion Fascia iliaca compartment block provides better analgesia than femoral nerve block in terms of facilitating optimal positioning for subarachnoid block in patients undergoing proximal femoral fracture fixation procedure. KEY WORDS Fascia iliaca compartment block, femoral nerve block, positioning pain, subarachnoid block
Breathing comfort associated with different modes of ventilation: A comparative study in non-intubated healthy Nepalese volunteers
(Kathmandu University, 2007) Baral, PR; Bhattarai, B; Pande, R; Bhadani, U; Bhattacharya, A; Tripathi, M
Objective: To compare subjective experience of comfort associated with various commonly used supportive modes of mechanical ventilation for weaning in the intensive care unit (ICU). Subjects and Methods: The study was carried out in general ICU of a community-based teaching hospital in 30 healthy adult Nepalese volunteers of either sex and 19-37 years of age. The subjects were randomly made to experience breathing via anatomical facemask through ventilator circuit with synchronized intermittent mandatory ventilation (SIMV), assisted spontaneous breathing (ASB), biphasic positive airway pressure (BiPAP), and continuous positive airway pressure (CPAP) modes of ventilation with parameters set at intermediate level of respiratory support. Subjective comfort of breathing was noted using a 10cm visual analogue scale (VAS) with no discomfort at one end and maximum imaginable discomfort at the other. Inspiratory and expiratory experience of discomfort was also noted using a four point ranking scale (0-no discomfort, 1-mild discomfort, 2-moderate discomfort and 3-severe discomfort). In addition, presence or absence of feeling of breathlessness and inflation was also noted. Results: BiPAP was the most comfortable mode of ventilation (p<0.01) on visual analogue scale. SIMV and CPAP modes were associated with higher discomfort than other modes during inspiratory and expiratory phases respectively. Breathlessness and inflation were least felt in BiPAP and SIMV modes respectively. Conclusion: Perception of breathing comfort can vary widely with various supportive modes of ventilation in the ICU. Hence, no single supportive mode should be used in all patients during weaning from mechanical ventilation. Key words: assisted spontaneous breathing; biphasic positive airway pressure; breathing comfort; continuous positive airway pressure; mechanical ventilation; supportive modes synchronized intermittent mandatory ventilation; weaning
Comparative Study of Hyperbaric Bupivacaine Plus Ketamine Vs Bupivacaine Plus Fentanyl for Spinal Anaesthesia during Caeserean Section
(Kathmandu University, 2013) Shrestha, SK; Bhattarai, B; Shah, R
ABSTRACT Background Spinal anesthesia is widely used for caesarean section due to its rapid onset, low failure rate, complete analgesia. Addition of intrathecal ketamine and opioids to local anaesthetics seems to improve the quality of block and prolong the duration of analgesia. Objectives The purpose of this study was to compare the effect of intrathecal ketamine mixed with hyperbaric bupivacaine to intrathecal fentanyl mixed with hyperbaric bupivacaine. Methods One hundred parturients ASA Grade I scheduled for elective or semiurgent caesarean section under spinal anaesthesia were randomly divided into two groups. Group A received 2ml (10 mg) hyperbaric bupivacaine 0.5% plus 25 mg preservative free ketamine. Group B received 2ml (10mg) hyperbaric bupivacaine 0.5% plus 25μg fentanyl. The patients were observed intraoperatively for the onset of sensory block, degree of motor block and total duration of analgesia. Results The time to achieve Bromage scale 3 motor blockade was shorter in Group A than in Group B.(p= 0.445) whereas time to achieve highest dermatomal level of sensory block was shorter in Group A than in Group B (p= 0.143). The duration of spinal analgesia was longer in Group B than in Group A (p= 0.730). The frequency of side effect such as sedation score was higher in Group A compared to Group B (p= 0.048). The incidence of pruritus was significantly higher in Group B compared to Group A (p = 0.000). Conclusion Addition of preservative free ketamine lead to faster onset of sensory and motor blockade, although it did not prolong the duration of spinal analgesia compared to addition of fentanyl in parturients undergoing caesarean section with spinal anaesthesia. KEY WORDS Bupivacaine, caesarean section, fentanyl, ketamine, spinal anaesthesia
Comparison of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy
(Kathmandu University, 2011) Bhattarai, B; Shrestha, SK; Kandel, S
ABSTRACT Background The ability of good glottis visualization during direct laryngoscopy is major determinant of easy tracheal intubation. Sniffing position for laryngoscopy is considered as gold standard and ideal position. Several studies have questioned the validation of sniffing potion. Objectives This study aims to compare relative efficacy of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy. Methods Four hundred patients undergoing elective surgery under general anesthesia requiring endotracheal intubation were randomized into two groups and study was concluded. Glottic visualization was assessed using modified Cormack and Lehane classification. After laryngoscopy, tracheal intubation was performed and intubation difficulty scale was noted. Results Both the groups were comparable regarding glottis visualization. Both the groups were comparable in demographic profiles. All the intubation difficulty scale variables were comparable in both the groups except N3. Total Intubation Difficulty Score was better in sniffing position than in simple head extension group. Conclusion Glottic visualization and intubation difficulty score was better in sniffing position as compared to simple head extension. KEY WORDS sniffing position, simple head extension, direct laryngoscopy
Critical illness myopathy
(Kathmandu University, 2008) Bhattarai, B; Kulkarni, AH; Ranjan, RK; Ambareesha, M
Abstract Critical illness myopathy is one of the causes for failure to wean from ventilator. Although associate factors of dysectrolytemia is to be ruled out and other causes for failure to wean is to be ruled out before diagnosing critical illness myopathy. Several factors play role in development of this condition. Here we present a case report of a post partum patient where we had encountered failure to wean despite several attempts and at last was successfully weaned and discharged from Intensive care unit. Key words: critical illness, myopathy, weaning
Incidence and Risk Factors for Ventilator-Associated Pneumonia in Kathmandu University Hospital
(Kathmandu University, 2011) Ranjit, S; Bhattarai, B
ABSTRACT Background Ventilator associated pneumonia is a major cause of morbidity in the intensive care unit. Difficulties in identification of the risk factors, in diagnosing and in prevention, have intensified the problem. Objectives To measure the incidence of ventilator associated pneumonia in intensive care unit and to identify the risk factors associated. Methods A prospective observational cohort study of 69 patients who were mechanically ventilated for more than 48 hours were evaluated to find out the development of nosocomial pneumonia and presence or absence of risk factors. Data were subjected to univariate analysis using chi-square and t-test. Level of significance was set at 0.05. Results Twenty two (31.88%) out of 69 patients developed ventilator associated pneumonia, majority of them between four days to 14 days. Reintubation, invasive lines, H2 blockers and low PaO2/FiO2 were identified as major risk factors in our study. Enteral feeding via nasogastric tube and use of steroids was not associated with development of ventilator associated pneumonia. The patients with ventilator associated pneumonia had significantly longer duration of mechanical ventilation (18.88±7.7 days vs 7.36±4.19 days) and stay (29±17.8 days vs 9.22±5.14 days). The morality was similar for both the groups with or without ventilator associated pneumonia. Conclusion The incidence of ventilator pneumonia is high. Patients requiring prolonged ventilation, re-intubation, more invasive lines and H2 blockers, are at high risk and need special attention towards prevention. KEY WORDS nosocomial infection, prolonged mechanical ventilation, risk factors, ventilator associated pneumonia
Incidence of Hypertension in Patients Undergoing Surgery at Dhulikhel Hospital - Kathmandu University Hospital
(Kathmandu University, 2011) Sapkota, S; Sherpa, M; Bhattarai, B
ABSTRACT Background Hypertension is an important public health challenge worldwide and is most important modifiable risk factor for cardiovascular, cerebrovascular and renal disease. Blood pressure determination forms an integral part of anaesthesiologist’s evaluation of hispatient’s condition prior to and during surgery. Data are not available which indicate changes in blood pressure occurring preanaesthetically in hospitalized patients. There are several risks from untreated preoperative hypertension in perioperative and postoperative phase. Objective To know the incidence of hypertension in preoperative patients undergoing major surgery Methods This retrospective observational study was based on the data collected from preanaesthetic checkup record book from January 2010 to December 2010. Results A total of 955 patients were studied and analyzed in terms of hypertension and demographic characteristics. The total incidence of hypertension in preoperative phase was 10.16%. Among them 64.9% being male and 35.1% female. Maximum incidence was found in age group 50-59 years i.e. 26.6%. Among the case detected maximum patients i.e. 52% were patients with newly diagnosed hypertension and among those under medications 61.1% were using calcium channel blockers. Conclusion Knowing the incidence will help in proper preoperative optimization of the hypertensive patients and also help in decreasing the incidence of postoperative complications.. KEY WORDS anaesthesia, calcium channel blockers, diuretics, hypertension,
Negative Pressure Pulmonary Edema- Case Series and Review of Literature
(Kathmandu University, 2011) Bhattarai, B; Shrestha, S
ABSTRACT Post obstructive pulmonary edema (POPE) also known as Negative pressure pulmonary edema (NPPE)is potentially life threatening complication. It occurs in about 0.1% of anesthetics and is related to upper airway obstruction. Two types have been described in literature. Different etiology has been attributed to development of Negative pressure pulmonary edema. Early identification and treatment of predisposing factor along with proper monitoring of this complication early treatment should be instituted because resolution is also fast and in most cases without residual effects. KEY WORDS negative pressure pulmonary edema, complication, post operative
Perception About the Role of Anesthesia and Anesthesiologist Among the Paramedical Staffs: Perspective from a Medical College in Nepal
(Kathmandu University, 2012) Bhattarai, B; Kandel, S; Adhikari, N
ABSTRACT Background Anesthesiologists and anesthesia has been considered behind the scene. The image and status of anesthesiologist in the eyes of the medical and lay communities has always been a problem. Objectives This study was designed to assess the knowledge about the role of anesthesiologist among the paramedical staffs at Kathmandu University Hospital. Methods This prospective questionnaire based study was done at Kathmandu University School of Medical Science, Dhulikhel Hospital for 2nd January 2011 to 30th Jan 2011 among the paramedical staffs working in different department of the hospital. Results There were 150 questionnaire distributed out of which 120 responded. Mean Age was 23.33 and most of the respondents were female with majority having education qualification equivalent to intermediate level. Only 49.20 said it to be a different specialty and 72.5% said anaesthesiologist work differently in the theatre where as 70% knew anaesthesiologist did something in the post-operative period too. Conclusion Anesthesiologists have duty to visit patient’s pre operatively and post operatively. The role inside the theatre and expanding role outside the theatre is poorly known. The awareness about the role of anesthesiologist in operation theatre, in intensive care unit, acute and chronic pain management and emergency care areas should be highlighted to all the staffs. KEY WORDS Anaesthesia, paramedical
Postoperative Analgesic Effect of Morphine Added to Bupivacaine for Transversus Abdominis Plane (TAP) Block in Appendectomy
(Kathmandu University, 2017) Ghimire, A; Bhattarai, B; Prasad, JN; Subedi, A; Thapa, P; Limbu, PM; Adhikari, S
ABSTRACT Background Transversus abdominis plane (TAP) block with local anaesthetics produces effective pain relief following lower abdominal surgeries. Although opioids have been found to have effects through peripheral receptors also, reports on their effect when used as additive to local anaesthetics for TAP block are lacking. Objective To assess the analgesic effect of peripherally administered morphine with bupivacaine for ipsilateral TAP block in patients undergoing emergency appendectomy under general anaesthesia. Method Sixty patients undergoing appendectomy were randomized to undergo ipsilateral TAP with 20 ml of 0.5% bupivacaine plus 2 ml of NS (total 22 ml) and 2 ml of intravenous (IV) saline (Group TB) or with 20ml of 0.5% bupivacaine plus 2 mg (2 ml) of morphine (total 22 ml) and 2 ml of NS IV (Group TBM) or with 20 ml of 0.5% bupivacaine plus 2 ml of NS (total 22 ml) and 2 mg (2 ml) IV morphine (Group TB-IVM). Pain severity was measured using Visual Analogue Scale (VAS) preoperatively (Baseline) and at 30 min, 6h, 12 h and 24 h postoperatively. Inj. tramadol 50 mg IV was used as rescue analgesic when postoperative VAS was 4 or more. The duration of analgesia (time to first analgesic) and the postoperative 24 h tramadol requirement was recorded. Result The mean duration of analgesia in Group TBM was significantly longer (801.50 ± 74.92 min, p=0.002) than in Group TB (720.00 ± 42.17 min) and Group TB-IVM (712.70 ± 40.94 min). The mean postoperative 24 h tramadol requirement was also less in Group TBM (69.23 ± 25.31mg) than in Groups TB (100.00 ± 38.34 mg) and TB-IVM (95.00 ± 39.40 mg) but did not reach the level of statistical significance (p=0.057). Significantly less ondansetron was required in Group TBM (3.80 ± 2.04 mg) than in Group TB (6.80 ± 2.93 mg) and TB-IVM (6.00 ± 2.75 mg) (p=0.002). Conclusion Morphine added to bupivacaine effectively prolongs the analgesic duration of TAP block in appendectomy. KEY WORDS Morphine, postoperative analgesia, transversus abdominis plane block, USG guided
Postoperative Nausea and Vomiting in Patients Undergoing Total Abdominal Hysterectomy Under Subarachnoid Block: A Randomized Study of Dexamethasone Prophylaxis
(Kathmandu University, 2012) Khatiwada, S; Bhattarai, B; Biswas, BK; Pokharel, K; Acharya, R; Singh, SN; Uprety, D
ABSTRACT Background Postoperative nausea and vomiting is a common distressing problem in patients undergoing gynaecological surgery under anaesthesia including central neuraxial blockade, which requires frequent medical interventions. Objectives We aimed to find out the antiemetic effect of prophylactic dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block. Influences of dexamethasone on patient satisfaction and postoperative analgesia were also observed as secondary objectives. Methods This was a prospective, randomized, double blind, placebo controlled study conducted in BPKIHS, a Tertiary care University based hospital from January 2009 to April 2009, for a period of four months. This study involved 80 American Society of Anaesthesiologist Physical Status I&II patients undergoing total abdominal hysterectomy under subarachnoid block. Patients were divided into two groups of 40 each to receive either 4 mg of dexamethasone (group D) or normal saline (group N) in volume of 2 ml intravenously 1 hourr prior to subarachnoid block. Surgery was allowed to start with block height of at least T8 dermatome. Intraoperative and postoperative nausea and vomiting was observed using nausea and vomiting scale every 4 hour for 24 hours. Results Seven (17.4%) patients in group D and 11 (27.5%) patients in group N had nausea and vomiting in the intraoperative period (P=0.284). Sixteen (40%) patients in group D experienced nausea and vomiting in the postoperative period as compared to 27 (67.5%) in group N (P =0.0136). Accordingly, the mean requirement of rescue antiemetic was less in group D compared to Group N (P=0.042). Further, only 15 (37.5%) patients in group D required postoperative supplemental analgesic as compared to 23 (57.5%) in group N (P=0.058). After 24 hrs of surgery, 26 (65%) patients expressed satisfaction in group D as compared to 16 (40.0%) in group N (P =0.025). Conclusions Use of dexamethasone prior to subarachnoid block in patients undergoing total abdominal hysterectomy significantly reduces the incidence of nausea and vomiting and the requirement of antiemetic in the postoperative period, with better patient satisfaction. KEY WORDS Dexamethasone, gynaecological surgery, postoperative nausea and vomiting, subarachnoid block
Preemptive use of Small Dose Fentanyl Suppresses Fentanyl Induced Cough
(Kathmandu University, 2012) Shrestha, SK; Bhattarai, B; Shah, RS
ABSTRACT Background Fentanyl, a synthetic opioid, is a popular choice amongst anaesthesiologists in the operating room. Pre induction intravenous fentanyl bolus is associated with coughing in 28 – 65% of patients. Fentanyl induced cough is not always benign and can be remarkably troublesome at the most critical moment of anaesthesia when airway reflex is lost. Objectives To study the effect of pre emptive use of minimal dose fentanyl through the peripheral venous cannulae on the incidence of cough by a larger bolus of intravenous fentanyl. Methods One hundred and fifty patients aged 18 -75 years undergoing elective surgical procedures were randomized into three groups of 50 each. The first group received 0.5 ml saline 0.9 % intravenously one minute prior to the administration of fentanyl 150μg (3 ml); the second group received pre emptive fentanyl 25μg(0.5ml) prior to the administration of fentanyl 125μg(2.5ml); and the third group received preemptive fentanyl 25 μg(0.5ml), followed by the administration of fentanyl 150μg(3ml).. Based on the number of coughs observed, cough severity was graded as mild(1-2), moderate (3-5),or severe (>5). Results The incidence of fentanyl induced cough was significantly lower in both pre emptive group 4(8%) for 125μg fentanyl and 7(14%) for 150μg than in the saline group 15(30%). Conclusion Pre- emptive use of minimal dose fentanyl 25μg administered one minute before a larger bolus dose of fentanyl (125 or 150μg ) can effectively suppress cough. KEY WORDS Cough, fentanyl, pre emptive
Propofol Sedation During Spinal Anaesthesia - A Dose Finding Study
(Kathmandu University, 2011) Ghimire, A; Bhattarai, B; Rahman, TR; Singh, SN; Koirala, S; Tripathi, M
ABSTRACT Background It is important to be able to measure and maintain a specific sedation level to compare outcomes of different levels of sedation during anesthesia and the aims include general patient comfort, freedom from specific discomfort, and some amnesia for both the block procedure and the surgical operation, in order to meet the patient’s preference and safety. In this prospective randomized clinical study, we compared the three different infusion doses of propofol. Objective To find out the appropriate infusion dose of propofol for optimal sedation without causing undue side effects in patients undergoing spinal anaesthesia. Method One hundred twenty patients ASA PS I-II were randomly allocated to three groups 1, 2 and 3 receiving propofol infusion at the rate of 25, 50 and 75 microgram/kg/ min with concentration of (0.5%), (1%) and (1.5%) respectively. They were observed for sedation score, hemodynamic parameters and satisfaction level. The adverse effects like respiratory depression, nausea and vomiting score were assessed. Result Median sedation score increased in a dose dependent manner, with significantly higher scores in group 2 and 3 compared with group 1. Hemodynamic parameters were better in group 1 and 2 as judged by mephentermine requirement. The awakening time after stoppage of infusion was significantly delayed in group 3 (p < 0.001). Respiratory depression, nausea and vomiting were comparable clinically. Almost three fourth of the patients were satisfied with the techniques used. Conclusion Propofol infusion at the rate of 50mcg/kg/min for sedation in spinal anaesthesia provides optimal sedation, early awakening and excellent satisfaction level in the postoperative period KEYWORDS propofol, sedation, spinal anaesthesia.
The Analgesic Effectiveness of Ipsilateral Transversus Abdominis Plane Block in Adult Patients Undergoing Appendectomy: A Prospective Randomized Controlled Trial
(Kathmandu University, 2015) Ghimire, A; Bhattarai, B; Prasad, JN; Shah, SP
ABSTRACT Background Transversus abdominis plane block (TAP) has been shown to produce effective pain relief following lower abdominal surgeries but is yet to be routinized in different type of surgeries including appendectomy. The main risk of visceral injury can be logically avoided when the block is performed with the abdomen open using landmark technique in the absence of ultrasound guidance. Objective To assess the effectiveness of TAP block with bupivacaine for postoperative analgesia using landmark technique (performed with the abdomen open) in adult patients undergoing appendectomy. Method Forty patients undergoing appendectomy were randomized to undergo ipsilateral TAP block with bupivacaine (n=20) versus control (n=20) in addition to standard postoperative analgesia. All patients received standard general anaesthesia. The block was performed using the landmark technique with 20 ml of 0.5% bupivacaine or isotonic saline on ipsilateral side just before abdominal closure. Pain severity was measured using Visual Analogue Scale (VAS). Tramadol 50 mg was administered as rescue analgesic intravenously when VAS was four or more postoperatively. The duration of analgesia and the requirement of tramadol in 24 hours postoperatively were recorded. Result Mean duration of analgesia in the TAP block with bupivacaine was longer as compared with placebo (724.00±299.07 min vs 168.25±55.18 min; p< 0.01). The TAP block with bupivacaine compared with saline significantly reduced postoperative VAS pain scores. Mean tramadol requirement in the first 24 hours was also reduced (42.50±37.25 mg vs 120.00±55.18 mg; p<0.01). There were no significant complications attributable to the TAP block. Conclusion Ipsilateral TAP block with bupivacaine using landmark technique with the abdomen open in appendectomy provides effective postoperative analgesia and opioids sparing effect. KEY WORDS Ipsilateral, landmark technique, postoperative analgesia, transversus abdominis plane block

Browsing by Author "Bhattarai, B"

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