Kirti N Saxena

Role of transcutaneous electrical nerve stimulation in post-operative analgesia.

The use of transcutaneous electrical nerve stimulation (TENS) as non-pharmacological therapeutic modality is increasing. The types of TENS used clinically are conventional TENS, acupuncture TENS and intense TENS. Their working is believed to be based on gate control theory of pain and activation of endogenous opioids. TENS has been used in anaesthesia for treatment of post-operative analgesia, post-operative nausea vomiting and labour analgesia. Evidence to support analgesic efficacy of TENS is ambiguous. A systematic search of literature on PubMed and Cochrane Library from July 2012 to January 2014 identified a total of eight clinical trials investigating post-operative analgesic effects of TENS including a total of 442 patients. Most of the studies have demonstrated clinically significant reduction in pain intensity and supplemental analgesic requirement. However, these trials vary in TENS parameters used that is, duration, intensity, frequency of stimulation and location of electrodes. Further studies with adequate sample size and good methodological design are warranted to establish general recommendation for use of TENS for post-operative pain.

A comparative randomized study of paravertebral block versus wound infiltration of bupivacaine in modified radical mastectomy

Background: Paravertebral block (PVB) has the potential to offer long-lasting pain relief because it can uniquely eliminate cortical responses to thoracic dermatomal stimulation. Benefits include a reduction in postoperative nausea and vomiting (PONV), prolonged postoperative pain relief, and potential for ambulatory discharge. Aims: To compare PVB with local infiltration for postoperative analgesia following modified radical mastectomy (MRM). Methods: Forty patients undergoing MRM with axillary dissection were randomly allocated into two groups. Following induction of general anesthesia in group P, a catheter was inserted in the paravertebral space and 0.3 ml/kg of 0.25 % of bupivacaine was administered followed by continuous infusion, while in group L, the surgical incision was infiltrated with 0.3 ml/kg of 0.25 % bupivacaine. Statistical Analysis: The statistical tests were applied as unpaired student ‘t’ test/nonparametric test Wilcoxon Mann Whitney test for comparing different parameters such as VAS score and consumption of drugs. The categorical variables such as nausea and vomiting scores, sedation score, and patient satisfaction score were computed by Chi square test/Fisher exact test. Results: VAS score was significantly lower in group P than in group L throughout the postoperative period. The mean alertness score (i.e., less sedation) was higher in group P in the postoperative period than group L. The incidence of PONV was less in PVB group. Conclusion: PVB at the end of the surgery results in better postoperative analgesia, lesser incidence of PONV, and better alertness score.

Pulmonary oedema following topical phenylephrine administration in a child anaesthetised for cataract extraction

2 Dinkel HP, Muhm M, Exadaktylos AK et al. Emergencypercutaneous retrieval of a silicone port catheter fragment inpinch off syndrome by means of an Amplatz gooseneck snare.Emerg Radiol 2002; 9: 165–168.3 Surov A, Jordan K, Buerke M et al. Atypical pulmonaryembolism of port catheter fragments in oncology patients.Support Care Cancer 2006; 14: 479–483.4 Nuss R, Cole L, Le T et al. Pinch off syndrome in patients withsickle cell disease receiving erythrocytapheresis. Pediatr BloodCancer 2008; 50: 354–356.5 Mirza B, Vanek VW, Kupensky DT. Pinch-off syndrome: casereport and collective review of the literature. Am Surg 2004; 70:635–644.

Klippel-Feil syndrome and neuraxial anaesthesia.

Klippel-Feil syndrome (KFS) is an uncommon congenital disorder characterised by fusion of two or more cervical vertebrae. The perioperative anaesthetic management in these patients is complicated by anatomical changes, which presupposes the presence of difficult airway and by presence of multiple associated congenital anomalies. Literature search for anaesthetic management of KFS patient showed paucity of reports employing neuraxial technique.

Comparative evaluation of transversus abdominis plane block with transcutaneous electrical nerve stimulation for postoperative analgesia following lower segment caesarean section

Background : Pain relief after caesarean is more compelling than any other surgery. As most commonly used modalities are associated with various side-effects, a multimodal approach is recommended. Transversus abdominis plane (TAP) block and transcutaneous electrical nerve stimulation (TENS) as part of multimodal postoperative analgesia regimes have been shown to be promising following caesarean section. Materials and Methods : 40 patients undergoing caesarean section under spinal anaesthesia were randomly allocated into 2 groups, first group receiving TAP block and second receiving TENS. In postoperative period pain, nausea and vomiting, sedation was recorded at 30 minutes, 2, 4, 6, 12 and 24 hours. Results : Both TAP block and TENS were effective for post caesarean analgesia as a part of multimodal regimen. In both groups VAS was less than 3 at each time interval. None of the patients required rescue analgesia. There was no complication with TAP block. Three patients in TENS group complained of discomfort and apprehension because of tingling sensation of TENS. Conclusion : Both TAP block and TENS as a part of multimodal analgesia are effective following caesarean delivery. Both decrease requirement of opioids and thus associated side effects as a result of which the mother is able to care for baby more effectively.

Awake Fibreoptic Intubation in the Sitting Position in a Patient with a Huge Goitre

A 46-year-old woman was anesthetized for total thyroidectomy. The thyroid was massive, deviating the trachea to the right and causing attenuation of the trachea radiologically. She had symptoms of respiratory obstruction in the supine position. Awake FOB-guided intubation was done in sitting position after airway topicalisation, and the airway was intubated with difficulty with 7.0 mm cuffed orotracheal tube. We describe this case in detail and discuss the significance of careful approach to planning and preparation in the management of such a case.

Laryngeal web in an infant with ventricular septal defect: a case of misdiagnosed congestive heart failure

1 Gislason T, Benediktsdottir KR. Snoring, apneic episodes and nocturnal hypoxemia among children 6 months to 6 years old. Chest 1995; 107: 963–966. 2 Carroll JL, Mc Colley SA, Marcus CL et al. Inablitity of clinical history to distinguish primary snoring from obstructive sleep apnea in children. Chest 1995; 108: 610–618. 3 Ward SLD, Marcus CL. Obstructive sleep apnea in infants and young children. J Clin Neurophysiol 1996; 13: 198–207.

Quadratus lumborum block for post-caesarean analgesia

There are two studies on QLB for post‐operative analgesia after caesarean section, and both reported QLB to significantly reduce morphine consumption in combination with multimodal analgesia regime.[1,2] In both the studies, posterior approach for QLB was used with the patient in the supine position. The advantages of the posterior approach compared to anterolateral and transmuscular approach are more superficial point of injection, better ultrasonographic resolution and potentially safer injection as intraperitoneal contents are at a further distance.[1] Compared to transversus abdominis plane (TAP) block, QLB has been noted to provide widespread analgesia of longer duration. The sensory levels obtained by QLB were T7 and T12 dermatomes, whereas TAP block affected T10 and T12 dermatomes. This can be explained by spread either in the thoracolumbar plane or into the paravertebral space. The extensive spread has been postulated to provide analgesia for visceral component of pain along with somatic. The duration of analgesia after QLB exceeded 24 h and was significantly longer than that for TAP block.[2] However, the post‐operative analgesic regime in both studies included patient‐controlled analgesia morphine and the cumulative consumption measured at various intervals could have been affected by use of morphine for non‐operative pain. Further studies are required for validation of analgesic efficacy of QLB. Another important consideration is that QLB is purely an ultrasound‐guided block and requires a clear knowledge of anatomy for safe performance. A number of vital structures including the kidney and lumbar arteries running behind QL muscle are susceptible to injury. In patients receiving anticoagulant therapy, the QLB should be carefully considered due to the vascularity of area, retroperitoneal spread of haematoma and proximity to paravertebral area and lumbar plexus.[3]

Post-caesarean analgesia: What is new?

Adequate post-operative analgesia after caesarean section (CS) is vital as it impacts the distinct surgical recovery requirements of the parturient. Although newer analgesic modalities and drugs for post-caesarean analgesia have been introduced over the recent years, review of the literature suggests suggests that we are far from achieving the goals of optimum post-operative analgesia. We conducted a systematic review of recent advances in modalities for post-caesarean analgesia. After systematic search and quality assessment of studies, we included a total of 51 randomised controlled trials that evaluated the role of opioids, transversus abdominis plane (TAP) block, wound infiltration/infusion, ketamine, gabapentin and ilioinguinal-iliohypogastric nerve block (II-IH NB) for post-caesarean analgesia. Administration of opioids still remains the gold standard for post-operative analgesia, but the associated troublesome side effects have led to the mandatory incorporation of non-opioid analgesics in post-CS analgesia regime. Among the non-opioid techniques, TAP block is the most investigated modality of the last decade. The analgesic efficacy of TAP block as a part of multimodal analgesia is established in post-CS cases where intrathecal morphine is not employed and in CS under general anaesthesia. Among non-steroidal anti-inflammatory drugs, COX-I inhibitors and intravenous paracetamol are found to be useful in post-operative analgesic regimen. The perioperative use of ketamine is found useful only in CS done under spinal anaesthesia; no benefit is seen where general anaesthesia is employed. Wound infiltration with local anaesthetics, systemic gabapentin and II-IH NB need further trials to assess their efficacy.

Intrathecal catheterisation for accidental dural puncture: A successful strategy for reducing post-dural puncture headache.

The incidence of accidental dural puncture (ADP) varies from 0.19% to 3.6%[1] during epidural space identification and warrants a prompt response. The possible options include; conversion to spinal anaesthesia by injection of hyperbaric drug through the same epidural needle, placement of the epidural catheter in another interspace, intrathecal catheterisation through the dural hole or less commonly abandoning the procedure.[2,3] Although the first two options may help to tide over the immediate anaesthetic/analgesic requirements, post-dural puncture headache (PDPH) remains a major concern.[1,2]