Jyotsna Wig

Postoperative pain assessment in preverbal children and children with cognitive impairment

Postoperative pain assessment and management in preverbal children and children with cognitive impairment poses major challenges to pediatric anesthesiologists. An accurate diagnosis of extent of pain is the keystone for the successful management of pain. This article reviews the neurobiology of pain at birth, long‐term consequences of early pain and different pediatric pain assessment tools used for postoperative assessment in infants, young children, and children with cognitive disabilities.

Laryngeal mask airway insertion in children: comparison between rotational, lateral and standard technique

Background:  The purpose of the study was to compare the success and ease of insertion of three techniques of laryngeal mask airway (LMA) insertion; the standard Brain technique, a lateral technique with cuff partially inflated and a rotational technique with cuff partially inflated.

Subtenon Block Compared to Intravenous Fentanyl for Perioperative Analgesia in Pediatric Cataract Surgery

BACKGROUND: General anesthesia with opioids provides good operative conditions for ocular surgery in children; however, postoperative pain management remains a significant problem. Regional anesthesia is commonly used as an adjunct to general anesthesia in children. We compared the efficacy and safety of subtenon block (SB) versus IV fentanyl for perioperative analgesia in pediatric cataract surgery. We hypothesized that perioperative analgesia using SB may reduce the requirement of postoperative rescue analgesia compared with fentanyl. METHODS: This was a prospective, randomized, controlled, double-blind trial. One hundred fourteen ASA I and II children (6 mo–6 yr) undergoing elective cataract surgery in one eye under general anesthesia were studied. Children were randomly allocated to one of the two groups, i.e., Group SB (n = 58) or Group F (n = 56) after securing the airway. Children in Group SB received SB with 0.06–0.08 mL/kg of 2% lidocaine and 0.5% bupivacaine (50:50) mixture and simultaneous 0.2 mL/kg normal saline IV, whereas children in Group F received 1 &mgr;g/kg (0.2 mL/kg of 5 &mgr;g/kg) of fentanyl IV and simultaneous subtenon injection with normal saline (0.06–0.08 mL/kg). Surgery started after 5 min of study drug administration. Postoperative assessment for pain, sedation, and nausea/vomiting was done at 0.5, 1, 2, 3, 4, and 24 h. The primary outcome was number of patients requiring rescue analgesia during the 24-h study period. Secondary outcomes assessed were pain and sedation scores, time to first rescue analgesia, incidence of occulocardiac reflex, and nausea/vomiting. RESULTS: The number of patients requiring rescue analgesia during the 24 h was significantly less in Group SB (n = 17/58, 29.3%) compared with Group F (n = 39/56, 69.6%, P < 0.001). The postoperative pain scores were statistically lower in Group SB at all time intervals. The median (range) time to first analgesic requirement was significantly prolonged in Group SB (16 [2–13] vs 4 [0.5–8.5] h in Group F) (P < 0.001). Sedation scores at ½ h were comparable, after which significantly more children were anxious or crying in Group F compared with Group SB in which more children were calm, sitting, or lying with eyes open and relaxed (P < 0.05). A significantly higher incidence of oculocardiac reflex was recorded in Group F versus Group SB (P = 0.019). No complication related to SB was noticed. CONCLUSIONS: SB is a safe and superior alternative to IV fentanyl for perioperative analgesia in pediatric cataract surgery.

Postoperative emergence delirium in pediatric patients undergoing cataract surgery – a comparison of desflurane and sevoflurane

Desflurane and sevoflurane are associated with postoperative emergence delirium (ED) in children. The study aimed to compare the use of desflurane and sevoflurane to determine the postoperative ED in children undergoing cataract surgery using the validated Pediatric Anesthesia Emergence Delirium (PAED) scale.

Lateral parasagittal versus midline interlaminar lumbar epidural steroid injection for management of low back pain with lumbosacral radicular pain: a double-blind, randomized study.

BACKGROUND:Epidural steroid injections are commonly used for management of low back pain with lumbosacral radicular pain and can be administered by either interlaminar or transforaminal routes. The transforaminal route is reported to be more effective than the interlaminar route due to higher delivery of drug at the ventral epidural space. However, the transforaminal route has been associated with serious complications including spinal cord injury and permanent paralysis. Hence, there is a search for a technically better route with fewer complications for drug delivery into the ventral epidural space. Recently, a parasagittal interlaminar (PIL) approach of epidural contrast injection was reported to have 100% ventral epidural spread. However, the therapeutic efficacy of this route has never been investigated. We compared the therapeutic efficacy of the PIL approach and midline interlaminar (MIL) approach. We hypothesized that the PIL approach may produce a better clinical outcome because of better ventral epidural spread of the drug compared with MIL approach. METHODS:Thirty-seven patients were randomized to receive injection of 80 mg methylprednisolone either by the PIL (PIL group, n = 19) or MIL (MIL group, n = 18) approach under fluoroscopic guidance. Patients were evaluated for effective pain relief (≥50% from baseline) by visual analog scale and improvement in disability by the modified Oswestry Disability Questionnaire at intervals of 15 days, 1, 2, 3, and 6 months. Patients having <50% pain relief from baseline received additional epidural injection of the same drug, dosage, and route, a maximum of 3 injections at least 15 days apart. The primary outcome of our study was the incidence of effective pain relief at 6 months. RESULTS:The incidence of patients having effective pain relief was higher with the PIL approach (13/19 [68.4%]) vs MIL (3/18 [16.7%]) at the end of 6 months. A significantly higher relative success of effective pain relief was noted in the PIL group (relative risk, 4.10; 95% confidence interval, 1.40–12.05; P = 0.001) at the end of the 6-month follow up with the requirement of fewer total injections (29 vs 41 in MIL, P = 0.043). Visual analog scale and modified Oswestry Disability Questionnaire scores were significantly lower in the PIL group compared with the MIL group at all time intervals after the procedure. Ventral epidural spread of contrast was significantly higher in the PIL 89.7% vs 31.7% in the MIL group. The administration of epidural steroid injection was without any complications with an exact 95% Clopper-Pearson confidence interval of 0.0% to 17.6% in the PIL group and 0.0% to 18.5% in the MIL group. CONCLUSIONS:Epidural steroid injection administered with the PIL approach was significantly more effective for pain relief and improvement in disability than the MIL approach for 6 months in the management of low back pain with lumbosacral radicular pain.

Effect of prophylactic ondansetron on postoperative nausea and vomiting in patients on preoperative steroids undergoing craniotomy for supratentorial tumors.

The exact incidence of postoperative nausea and vomiting (PONV) in patients on steroids undergoing neurosurgical procedures is not known. This prospective randomized double-blind study was planned to know the efficacy of prophylactic ondansetron in the prevention of PONV in patients on steroids as compared with placebo. Seventy adult patients of either sex who had received preoperative steroids (dexamethasone) for at least 24 hours and were scheduled to undergo craniotomy for supratentorial tumors were included. Patients were randomly allocated using a randomization chart to 1 of the 2 groups to receive either ondansetron 4 mg (group O) or 0.9% saline (group S) intravenously at the time of dural closure. Numeric Rating Scale score for nausea and pain intensity was recorded preoperatively and till 24 hours postoperatively. The 6-hour postoperative nausea score was significantly lower in group O [median, 0; interquartile range (IQR), 0 to 20] than in group S (median, 20; IQR, 0 to 20) (P<0.05). The incidence of vomiting was lower in group O (23%) than in group S (46%) (P<0.05). The total number of emetic episodes, the number of doses of rescue antiemetics given in the first 6 postoperative hours, and the total number of rescue antiemetics given were significantly lower in group O than in group S (P<0.05). Intravenous administration of 4 mg of ondansetron at the time of dural closure was effective in reducing the incidence of PONV and the rescue antiemetics requirement in patients on preoperative steroids undergoing craniotomy for supratentorial tumors.

Post-operative pain and analgesic requirements after paravertebral block for mastectomy: A randomized controlled trial of different concentrations of bupivacaine and fentanyl

Background: Paravertebral block (PVB) is useful for post-operative analgesia after breast surgery. Bupivacaine is used for PVB at higher concentrations (0.5%), which may lead to systemic toxicity after absorption. Therefore, we proposed to evaluate the efficacy of lower concentrations of bupivacaine with and without fentanyl for thoracic PVB in patients undergoing surgery for carcinoma breast. Methods: Forty-eight patients scheduled for surgery for breast cancer were enrolled in this prospective, randomized, double-blinded, placebo-controlled trial and were allocated to one of four groups: 0.25% bupivacaine with epinephrine 5 mcg/ ml, 0.25% bupivacaine + epinephrine 5 mcg/ ml with 2 mcg/ml fentanyl, 0.5% bupivacaine + epinephrine 5 mcg/ml or isotonic saline. PVB was performed and 0.3 ml/kg of the test drug was administered before induction of general anaesthesia. The primary outcome assessed was post-operative analgesic requirement for a period of 24 h. Secondary outcome measures were post-operative pain scores at rest and on movement of the arm, latency to first opioid, post-operative nausea and vomiting, quality of sleep, ability to move arm and patient satisfaction. Results: The patient characteristics and anaesthetic technique were comparable among the groups. The rescue analgesic consumption as well as cumulative pain scores at rest and on movement were significantly less in 0.25% bupivacaine+epinephrine with fentanyl and 0.5% bupivacaine+epinephrine groups (P<0.05). The average duration of analgesia was found to be 18 h after either 0.25% bupivacaine with epinephrine+fentanyl or 0.5% bupivacaine with epinephrine. Conclusions: Lower concentrations of bupivacaine can be combined with fentanyl to achieve analgesic efficacy similar to bupivacaine at higher concentrations, decreasing the risk of toxicity in PVB.

Intra-articular clonidine vs. morphine for post-operative analgesia following arthroscopic knee surgery (a comparative evaluation)

In a prospective, double-blind, randomised study, 30 ASA I patients were allocated to three groups in an attempt to find out the best post-operative analgesic following arthroscopic knee surgery under epidural anaesthesia. Group I patients received 5 mg of preservative-free morphine in 20 ml of normal saline, group II patients received 150 µg of clonidine in 20 ml of normal saline and group III patients received 20 ml of normal saline only. The post-operative pain was evaluated by a visual analogue scale and the need for rescue analgesic was assessed post-operatively for 12 h. We conclude that intra-articular administration of 150 µg of clonidine gives a longer lasting pain relief post-operatively (4-12 h) as compared to 5 mg of preservative-free morphine (3 h). No side effects were noted with either of the drugs.

Effect of intranasal dexmedetomidine or oral midazolam premedication on sevoflurane EC50 for successful laryngeal mask airway placement in children: a randomized, double-blind, placebo-controlled trial

This study was conducted to determine the effect of oral midazolam (OM) or intranasal dexmedetomidine (IND) on the EC50 of sevoflurane for successful laryngeal mask airway placement in children. We hypothesize that premedication with either agent might reduce the sevoflurane EC50 for laryngeal mask airway placement in children to a similar extent.

Fiber‐optic assessment of LMA position in children: a randomized crossover comparison of two techniques

Background:  This crossover study compared fiber‐optic assessment of laryngeal mask airway (LMA) position in children using two LMA insertion techniques, i.e., standard and rotational.