Bikram Kumar Gupta

A comparative study for post operative analgesia in the emergency laparotomies: Thoracic epidural ropivacaine with nalbuphine and ropivacaine with butorphanol

Background: Adequate postoperative pain therapy for emergency abdominal surgeries is important far beyond the perioperative period because sensitization to painful stimuli can cause postoperative morbidity. A prospective, double-blind, randomized study was carried out to compare the quality of postoperative analgesia and side-effect profile between epidurally administered butorphanol and nalbuphine as an adjuvant to 0.2% ropivacaine. Materials and Methods: A total of eighty patients, 43 men and 37 women between the age of 18 and 65 years of American Society of Anesthesiologists (ASA) Class I E and II E, who underwent intestinal perforation repair surgery were randomly allocated into two groups ropivacaine with butorphanol (RB) and ropivacaine with nalbuphine (RN), comprising of 40 patients each. Group RB received 0.2% ropivacaine containing 2 mg butorphanol while Group RN received 0.2% ropivacaine containing 10 mg nalbuphine through thoracic epidural catheter. Quality of analgesia, cardiorespiratory parameters, side-effects, and the need of rescue intravenous analgesia were observed. Results: The demographic profile and ASA Class were comparable between the groups. RN group had good quality of analgesia and stable cardiorespiratory parameters for the initial 6 h of postoperative period, after which they were comparable in both groups. Furthermore, the need of rescue analgesia was higher (20%) in the RB group during the first 6 h. The side-effect profile was comparable with a little higher incidence of nausea in both groups. Conclusion: Thoracic epidurally administered ropivacaine with nalbuphine is more effective than ropivacaine with butorphanol for immediate postoperative pain relief in patients undergoing emergency exploratory laparotomy.

Evaluation of USG Guided Transversus Abdominis Plane Block for Post-Operative Analgesia in Total Abdominal Hysterectomy Surgeries

Introduction and aims: Transversus abdominis plane (TAP) block is a fascial plane block providing postoperative analgesia in patients undergoing surgery with infraumbilical incision. This single blind prospective randomised control study aimed to evaluate the effectiveness of the TAP block for postoperative pain, as part of a multimodal analgesic regimen in patients undergoing TAH. Material and methods: Sixty adult female patients undergoing Total Abdominal Hysterectomy (TAH) under general anaesthesia were randomized to undergo TAP block with Ropivacaine along with intravenous paracetamol and diclofenac in group I (n=30) verses group II (n=30) with intravenous paracetamol and diclofenac alone. All patients were given inj. paracetomol 1 gm infusion and inj. diclofenac 75 mg intravenously along with induction of anaesthesia. Group I patients additionally received ultrasound guided TAP Block bilaterally with Ropivacaine (0.25%) (25 ml on either side). Each patient was accessed separately by blinded observer at regular interval up to 24 h for visual analogue scale (VAS), analgesic requirement, PONV and sedation using Ramsay sedation scale. If patients complained of pain or VAS>3, inj. Morphine 0.1 mg/kg was given. The observation in two groups was compared statistically using chi-square test and Paired t-test and analysed by SPSS version 18 software. Result: Result showed that the mean visual analogue score (VAS) of group1 was statistically less than group 2 (P<0.001). Mean analgesic requirement in mg for first 24 h postoperatively was significantly less in group 1 (5.40 ± 3.701) than group 2 (9.40 ± 3.856) Conclusion: TAP Block is easy to perform under ultrasound guidance without complication and it provides effective analgesia. TAP Block holds well as a part of multimodal analgesia regimen for patients undergoing Total Abdominal Hysterectomy.

Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt

Sir, Association of atrial septal defect (ASD) and pulmonary stenosis (PS) with bidirectional shunt in pregnancy is a very rare entity. Death can occur anytime during pregnancy or labour in these patients, precipitated by altered cardiovascular physiology of pregnancy.[1] A 25-year-old primi, an unbooked case with 38 weeks of gestation was posted for emergency caesarean section (CS) for cephalopelvic disproportion. In the second trimester, assessment of breathlessness (NYHA Grade III) with two-dimensional echocardiography revealed an ostium secundum type of ASD (8 mm × 10 mm) with predominantly right to left shunt (Qp: Qs - 0.85), severe PS (Maximum velocity [Vmax ]/peak pressure gradient [PGmax ] - 4.8 m/s/70.4 mm Hg), mild tricuspid regurgitation (Vmax /PGmax - 2.7 m/s/30.5 mm Hg), mild pulmonary regurgitation (Vmax /PGmax - 2.1 m/s/17.58 mm Hg), right ventricular hypertrophy (right ventricle diastolic wall thickness 6 mm) and normal biventricular function with ejection fraction of 60%. In the operation room, oxygen saturation (on room air) was 90-95%, pulse rate was 114/min regular and noninvasive blood pressure was 150/90 mmHg. The patient was premedicated with injection ranitidine (50 mg) and injection metoclopramide (10 mg) and colloid was started at 50 ml/h. Injection ceftriaxone 1 g was administered for antibiotic coverage. The initial central venous pressure was 13 cm H2O and was maintained between 12 and 14 cm H2O. Under aseptic precautions, an 18-gauge epidural catheter was inserted at L3 -L4 epidural interspace. A total volume of 20 ml local anaesthetic solution (13 ml of 2% lignocaine with adrenaline (5 μg/ml) and 1 ml of sodium bicarbonate and 1 ml (50 mg) of tramadol diluted with 5 ml saline) was administered through the epidural catheter in 5 ml increments for achieving a block height up to T4 dermatome. At the time of skin incision, injection ketamine (50 mg) and injection midazolam (1 mg) was administered in titrating doses. CS proceeded uneventfully, and a healthy male baby was delivered with Apgar score of 8 and 9 at 1 and 5 min, respectively. A bolus dose of 0.4 mg intravenous methylergometrine was administered slowly, and a slow infusion of oxytocin 10 units was started. The surgery lasted for about 60 min, and the blood loss was 500 ml. A total of 450 ml colloid and 100 ml oxytocin-normal saline infusion was given. Post-operative analgesia was provided with epidural top-up, whenever the patient complained of pain or visual analogue score was ≥4. At 48th h of follow-up, she had maximal scores for post-operative pain relief and overall satisfaction. She was discharged on the 7th post-operative day and referred to cardiology department for further management. The mortality in patients with ASD and severe PS with right to left shunt in pregnancy is unknown,[2] as many unsuccessful cases are not reported. In our case, although the patient was having reversal of shunt, she was asymptomatic and had no signs of chronic cyanosis. This may be due to hyperdynamic circulation of pregnancy producing increased pulmonary gradients and the restrictive ASD causing inadequate mixing of blood to produce clinical cyanosis.[3] Epidural anaesthesia (EA) was planned because of its slower onset and less and delayed haemodynamic variations compared to spinal and combined spinal-epidural technique.[4] General anaesthesia (GA) poses clear risks related to pulmonary vascular resistance and magnitude of the shunt. As the patient was in labour, we had no sufficient time for further cardiac evaluation. Pulse oximeter is used to assess the degree of right to left shunt during the peri-operative period.[5] Our principle was to maintain the cardiac output and to avoid the fall in systemic vascular resistance (SVR). We optimised the SVR based on mean arterial pressure to avoid the increase in shunt magnitude. Oxytocin bolus can cause direct vasodilatation and reduce SVR with a compensatory increase in heart rate and cardiac output in pregnant women. Use of methylergometrine lowered the use of vasoconstrictors[6] and added to haemodynamic stability. Colloids provide greater haemodynamic stability by remaining in the intravascular space for longer time and avoid volume overloading; this helps to decrease the magnitude of shunt and right ventricular failure.[7] The use of lower dose of lignocaine with adrenaline, bicarbonate and tramadol provided a more rapid onset and superior quality block to touch.[8] We did not institute any thromboprophylaxis measures; EA itself can reduce risk of perioperative venous stasis and embolism. To conclude, EA can be safely and effectively used for CS in pregnant patients having pulmonary vascular disease with reversal of shunts provided the SVR is maintained throughout the surgical procedure. Major haemodynamic complications and risk of embolism during GA can be avoided if EA is properly planned and administered. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Palatal pressure necrosis due to inappropriate size of Guedel's airway?

Sir, A 40-year-old male weighing 63 kg presented to Emergency Department with alleged history of road traffic accident 2 days ago with altered sensorium and seizures, referred from a rural hospital. He had a Guedels orophayrngeal airway size 4 (11 cm) (Romsons Scientific and Surgical Industries Pvt. Ltd., Agra, India) in situ firmly fixed with an elastic adhesive bandage. On initial assessment in the emergency scenario, the patient had a Glasgow Coma Score (GCS) of E3 V2 M5 with stable haemodynamics. A noncontrast computed tomography scan brain showed a left fronto-temporo-parietal subdural haematoma with underlying contusion with no mass effect and no evidence of any associated injuries. The patient was immediately shifted to our trauma Intensive Care Unit (ICU) for further management and monitoring. By the time patient reached the ICU, GCS deteriorated to E2 V1 M5 following a brief episode of seizure which lasted for 60 s. Hence, the decision was taken to perform rapid sequence induction using intravenous propofol (2 mg/kg) and injection rocuronium (1.2 mg/kg). On pulling out Guedels airway to perform oral suctioning before intubation, it was noticed that the mucosa of the palatal region had undergone blackish discolouration apparently due to the sustained pressure of the Guedels airway. However, the trachea was easily intubated with the appropriate size of the tracheal tube. In rural set ups such as ours, Guedels airway is commonly available and used as a bite guard as well as for maintaining an open airway and it is made up of elastomeric or plastic material. However, the lack of awareness among primary health care providers can lead to fatal complications during airway management, especially during emergencies. Ideally, an appropriate size airway should relieve/prevent obstruction of the airway by preventing the tongue from falling back. Pressure necrosis of lower lip due to incorrect placement of Guedels airway has also been reported.[1] The best criterion for proper size and position of the airway is an unobstructed gas passage. A method to ascertain the appropriate size of the airway by measuring the distance between the angle of mouth and mandible has been described.[2] Many primary care providers may not be aware of this. We also recommend that the manufacturers provide a diagrammatic depiction showing how to select proper size and insertion technique of airway on the package back cover to prevent such complications. In our case, palatal pressure necrosis may have occurred due to inappropriate size selection, prolonged placement and firm fixation of Guedels airway with a tight elastic adhesive bandage. There is need to emphasize the importance of using proper size of airway devices and teaching the healthcare workers of correct usage of the devices available to them. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Peri-operative management of a neonate with tracheo-oesophageal fistula and anorectal malformation: Survival of the fittest

Oesophageal atresia (OA) with tracheo‐oesophageal fistula (TOF) is a rare congenital anomaly usually seen in association with the VACTERL spectrum of disorders in neonates.[1] Management of these groups of anomalies is generally an early surgical intervention in most cases. Majority of neonates are managed with a palliative procedure until fit for a definitive surgery.[2] Isolated case reports have been published about management of multiple defects.[3,4] We describe a case of a neonate with a high anorectal malformation (ARM) along with TOF who was managed surgically in a single setting for both defects. The pathophysiology of TOF gets further accentuated in a setting of ARM as there is absolutely no way to decompress the bowel, either from above or below. This calls for an urgent intervention in the form of a colostomy/gastrostomy or definitive repair, given further compromise of the already susceptible lungs.

Erratum: Anatomical model broncho-trainer: A new training device: Corrigendum.

[This corrects the article on p. 481 in vol. 58, PMID: 25197126.].

Anatomical model broncho-trainer: A new training device.

481 Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014 Table 3: The initial rhythm and survival between the two groups Initial rhythm PEA VF Asystole ROSC Died Survived Percentage of survival Data A 31 18 29 50 54 24 30.8 Data B 28 16 34 51 65 13 16.6 Total 59 34 63 101 119 37 23 VF – Ventricular fibrillation; ROSC – Return of spontaneous circulation; PEA – Pulseless electrical activity