Ashok Kumar Saxena

Drotaverine hydrochloride for augmentation of labor

Objectives: To study the use of drotaverine hydrochloride for acceleration of labor and relief of labor pains. Methods: In this double‐blind placebo‐controlled randomized study, 100 primigravidas in uncomplicated spontaneous labor at term were given drotaverine hydrochloride or placebo (distilled water) intramuscularly. Labor events, including pain (assessed by a visual analog scale and a verbal rating scale), neonatal outcome, and side effects of the drug were recorded. Students t‐test was used for analysis. Results: Forty‐four patients in the drug group and 40 in the placebo group had complete data for analysis after decoding. In drotaverine group, there was a mean 15% reduction in the duration of the first stage of labor and a mean 19% reduction in the second stage. The maximum shortening of the first stage (28%) was observed when drotaverine was administered when cervical dilatation was 4 cm (P=0.044). There were no adverse fetal effects, but atonic postpartum hemorrhage was more common in the drotaverine group. There was no relief of pain with the drug except in the fourth stage of labor. Conclusions: Drotaverine hydrochloride is safe and effective in accelerating labor, but not effective in lessening labor pain.

A Randomized, Prospective Study of Efficacy and Safety of Oral Tramadol in the Management of Post‐Herpetic Neuralgia in Patients from North India

Objective:  To evaluate the safety and efficacy of oral tramadol therapy (50 to 200 mg/day) in the treatment for post‐herpetic neuralgia (PHN).

An Unusual Complication of Sinus Arrest Following Right‐Sided Stellate Ganglion Block: A Case Report

Abstract:  We present a case of a 29‐year‐old female patient who had presented to us for the management of her chronic right shoulder–hand pain and developed a sinus arrest following a right‐sided stellate ganglion block (RSGB). This patient on receiving a diagnostic RSGB via the anterior paratracheal (C6) approach developed sinus arrest followed by apnea and unconsciousness. On institution of resuscitative measures involving tracheal intubation, positive pressure ventilation, cardiac massage, and intravenous atropine, spontaneous cardiac activity recovered in about 3 minutes. Other signs and symptoms resolved fully in a total of 10 minutes. She had persistent postural hypotension lasting for about 24 hours requiring bed rest and was discharged about 36 hours after the procedure, without any adverse sequelae. As the sinus node is supplied by the right‐sided sympathetic chain, its blockade probably resulted in unopposed parasympathetic activity leading to asystole. Available evidence of the role of right stellate ganglion in regulation of cardiac electrophysiology and functioning is also discussed.

Technological advances in perioperative monitoring: Current concepts and clinical perspectives

Minimal mandatory monitoring in the perioperative period recommended by Association of Anesthetists of Great Britain and Ireland and American Society of Anesthesiologists are universally acknowledged and has become an integral part of the anesthesia practice. The technologies in perioperative monitoring have advanced, and the availability and clinical applications have multiplied exponentially. Newer monitoring techniques include depth of anesthesia monitoring, goal-directed fluid therapy, transesophageal echocardiography, advanced neurological monitoring, improved alarm system and technological advancement in objective pain assessment. Various factors that need to be considered with the use of improved monitoring techniques are their validation data, patient outcome, safety profile, cost-effectiveness, awareness of the possible adverse events, knowledge of technical principle and ability of the convenient routine handling. In this review, we will discuss the new monitoring techniques in anesthesia, their advantages, deficiencies, limitations, their comparison to the conventional methods and their effect on patient outcome, if any.

Medical termination of pregnancy in acute intermittent porphyria.

Acute intermittent porphyria is a rare autosomal dominant disease characterized by acute attacks of neuropsychiatric and neurovisceral dysfunction. In pregnancy, exacerbation of attacks in the form of seizures and acute abdomen occur due to hormonal changes. We report the case of a young woman presenting at 8 weeks of gestation requesting pregnancy termination. The patient suffered several episodes of acute abdomen and seizures in a prior pregnancy before the diagnosis was clinched. This case is reported because of its rarity and the limited obstetric experience of this disorder. Proper management depends on avoidance of precipitating factors. Anaesthetic drug safety in porphyria is reviewed and the choice of regional anaesthesia discussed

Current clinical opinions, attitudes and awareness of interns regarding post-operative and cancer pain management in a tertiary care centre

AIM This prospective study was aimed to assess the opinion, awareness and attitude of interns regarding pain assessment, pain management and common barriers in effective pain therapy for patients experiencing pain. MATERIALS AND METHODS A questionnaire including demographic details, knowledge of the tools of pain assessment, choice of drugs used, side effects, lacunae in existing knowledge and barriers in pain management was designed. A total of 160 interns were approached, out of which 149 returned the completed questionnaire. Only a few of them had a chance exposure to cancer pain management but none of them had undergone any formal training, teaching or classes in this field. RESULTS Most respondents knew that the pain can be measured and the ways to do it. A significant number considered morphine as the preferred drug for managing cancer pain and thought morphine is responsible for addiction and respiratory depression. About 72% interns knew about transdermal preparation of fentanyl and its usage in malignancy but only a few were aware of buprenorphine transdermal patch. Though they were enthusiastic about relieving the cancer patients from suffering, they had limited knowledge of how to achieve this. The common barriers identified by them were lack of adequate knowledge and training and limited availability of opioids. CONCLUSIONS The results of this study emphasize the need of special training programs pain management in order to change the current prevailing situation and improve the quality of analgesia provided to the patients.

CYP2D6*4 polymorphism, tramadol treatment and its clinical impact in patients with postherpetic neuralgia

AIM The aim of this study was to investigate the associations between the CYP2D6*4 polymorphism, interindividual differences in CYP2D6 activity and adverse drug effects in postherpetic neuralgia (PHN) patients receiving tramadol. PATIENTS & METHODS The study comprised 158 patients (including 78 nonresponders and 80 responders) with PHN who were undergoing analgesic treatment at the Pain Clinic in the Out Patient Department of the University College of Medical Sciences, Guru Teg Bahadur Hospital (New Delhi, India). The numerical rating scale scores were measured at the resting and movement stages; Neuropathic Pain Symptom Inventory scores were evaluated by the treating physician. WHO-brief questionnaire scores for quality of life and adverse drug effects during the time of study were recorded. All samples were analyzed for the CYP2D6*4 polymorphism using the PCR-restriction fragmentation length polymorphism method. RESULTS The genotype distribution did not vary significantly among different age groups in nonresponders and responders. The CYP2D6*4 polymorphism was significantly associated with lower Neuropathic Pain Symptom Inventory (burning, squeezing stabbing and pressure) scores. The quality-of-life (sociological, psychological and environmental domains) scores correlated with CYP2D6*4 and showed significant results (p < 0.05) using a generalized linear model. No association was found between the physiological domain compared with the CYP2D6*4 allele (p > 0.05). In addition, the homozygous mutated CYP2D6*4 allele was not related to adverse effects of analgesic therapy. CONCLUSION The CYP2D6*4 polymorphism may not be a predictor for treatment outcome of patients with PHN receiving tramadol. However, further investigation is required to confirm these findings in a larger sample size.

Anaesthetic concerns of a pregnant patient with Pott's spine for spine surgery in prone position

Sir, Surgical decompression is the treatment of choice in pregnancy complicated by spinal tuberculosis with neurologic deficit.[1] We report the anaesthetic management of a pregnant patient with Potts spine in prone position and discuss the various anaesthetic concerns including haemodynamic instability. A 23-year-old multipara, 17 weeks of gestation, weighing 52 kg, with Potts spine involving T7–T10 segments with progressive neurological deficit was scheduled for decompression and posterior screw fixation. Obstetricians opinion was sought. Preoperative foetal heart rate (FHR) was documented. Anti-aspiration prophylaxis was administered. Her baseline HR was 112/min and blood pressure (BP) was 132/82 mmHg. Invasive arterial BP monitoring could not be done due to the logistic problems. General anaesthesia was induced with propofol and morphine. Endotracheal intubation was facilitated using vecuronium with size 7.0 orotracheal cuffed tube. Injection glycopyrrolate 0.2 mg was administered as anti-sialagogue. Anaesthesia was maintained with isoflurane in 50% nitrous oxide and oxygen mixture. Soon following positioning, patient developed hypotension i.e., more than 20% fall from the baseline systolic BP (SBP). Fluid replacement and pressure-free abdomen were rechecked but the SBP continued to remain between 90 and 100 mmHg. Initially, hydrocortisone 100 mg was administered intravenously. The oozing from the surgical site resolved following injection tranexamic acid 500 mg. Surgery lasted for 5 h but BP persisted in the same aforementioned range. Blood loss was 1000 ml approximately. Haemodynamics and FHR remained stable post-operatively. The anaesthetic concerns related to spine surgery in pregnant patient include both obstetric and surgery-related i.e., prolonged surgery in prone position, major blood loss, relative hypotension and risk of postoperative visual loss.[2] The risk of radiation is of paramount concern due to the inability to use abdominal shield and the proximity of radiation to the foetus. The additional problem with prone position here includes the inability to perform emergent caesarean section. Technical problems may limit the usefulness of continuous FHR monitoring between 16 and 20 weeks and it is recommended to document FHR before and after surgery which was done in our patient. The American College of Obstetricians and Gynaecologists recommends continuous FHR monitoring in non-obstetric surgery from 18 to 20 weeks of gestation, based on the patient and the surgery to be performed.[3] There has been controversy related to the use of controlled hypotension and intraoperative tests/monitoring to detect spinal cord injury during pregnancy. Invasive arterial BP monitoring must be performed, more so, if controlled hypotension is instituted. Various risk factors for haemodynamic instability in these patients include pregnancy-induced aortocaval compression, massive fluid shift, blood loss and prolonged surgery. In addition, autonomic dysfunction has been reported as the cause for high incidence of intraoperative hypotension in adult patients with thoracic spine tuberculosis.[4] In our patient, vasopressor was not considered to treat hypotension:First, because, as the SBP remained in the acceptable range of 90–100 mmHg, and second, its use could have further led to increased blood loss. Since the hypotension occurred soon after positioning, it could be attributed by factors such as pregnancy-induced aortocaval compression, pre-operative hydration status and autonomic neuropathy related to thoracic spine tuberculosis. The initial two factors were ruled out by ensuring adequate fluid replacement and free and hanging abdomen in prone position. It is also reported that prone position in pregnant patient is associated with lesser risk of aortocaval compression than sitting or lateral position.[5] To conclude, intraoperative haemodynamic stability is of paramount anaesthetic concern in pregnant patients with thoracic spine tuberculosis and autonomic dysfunction must be considered as a potential cause for intraoperative hypotension. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Evaluation of PR, RR, QT intervals and QT dispersion following stellate ganglion block in chronic shoulder-hand pain patients.

Abstract:  Right stellate ganglion block (SGB) can increase QT interval, rate‐corrected QT interval (QTc), QT dispersion (QTD), rate‐corrected QTD (QTcD), and RR interval while left SGB can decrease these intervals in healthy volunteers. No such studies have been conducted in patients with chronic pain, hence this study was designed to investigate the effects of left and right SGB on these variables in chronic shoulder–hand pain patients. In this study, 28 patients with chronic shoulder–hand pain of at least 6 months duration were given right or left SGB depending on the shoulder affected. A 12‐lead electrocardiogram (ECG) was recorded before the block, 30 minutes and 60 minutes after the block. PR interval, RR interval, QT interval were recorded in all 12 leads while QTc, QTD, and QTcD were calculated. Right SGB was performed in 21 patients. A significant decrease (P < 0.05) in PR interval and a significant increase (P < 0.05) in RR interval, QT interval, and QTc interval were observed. QTD showed a significant increase (P < 0.05) only at 30 minutes after right SGB. Left SGB was performed in seven patients. A significant decrease (P < 0.05) in QT interval was observed throughout the study period, while QTc showed a significant decrease (P < 0.05) only at 60 minutes after the block. We conclude that right SGB induces significant increase of QT interval, RR interval, QTc interval, QTD, and a significant decrease of PR interval while left SGB produces a significant decrease in QT and QTc intervals in patients with chronic shoulder–hand pain.

Addressing the barriers related with opioid therapy for management of chronic pain in India

India has a high prevalence of chronic disorders which may be associated with persistent pain. Despite the availability of multiple treatment options, chronic pain is largely untreated and contributes to disability and mortality. Medical consumption of opioids remains low due to various barriers that prevent access to opioids for patients and healthcare practitioners. Stringent regulatory provisions outlined in the Narcotic Drugs and Psychotropic Substances Act (1985) have been major deterrents to adequate opioid use. Although multiple amendments to the act have ensured ease of opioid access for medicinal purposes, concerns such as lack of awareness and prescribing practices and attitudes of physicians/patients still need to be addressed. This review aims to identify these barriers and suggest recommendations to overcome them.