Medha Mohta

Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot study.

BACKGROUND Thoracic epidural analgesia (TEA), a commonly used analgesic technique in patients with multiple fractured ribs, is technically demanding and associated with certain side effects or complications. Thoracic paravertebral block (TPVB) is a simple and effective method of providing continuous pain relief in these patients. However, it has never been compared with TEA in terms of efficacy and outcome in patients with fractured ribs. METHODS Thirty adult patients of either sex, having three or more unilateral fractured ribs, were randomized to receive continuous bupivacaine infusion through either thoracic epidural or thoracic paravertebral catheter. Visual Analog Scale scores at rest and on coughing, respiratory rate, peak expiratory flow rate, and PaO2/FIO2 ratio were measured before and after administration of block at regular intervals. Morphine requirement for rescue analgesia, duration of bupivacaine infusion, length of intensive care unit and hospital stay, development of pulmonary complications, and complications of the two techniques were also recorded. RESULTS Both TEA and TPVB provided good pain relief and improved respiratory function, as evident by improvement in Visual Analog Scale scores at rest and on coughing, respiratory rate, and peak expiratory flow rate. However, no significant intergroup differences were found. Duration of bupivacaine infusion, morphine requirement, length of intensive care unit and hospital stay, and incidence of pulmonary complications were also similar in the two groups. Incidence of hypotension was more in TEA group. CONCLUSIONS Continuous bupivacaine infusion through TPVB is as effective as through TEA for pain management in patients with unilateral fractured ribs and the outcome after two techniques is comparable.

Psychological care in trauma patients

The clinician manages trauma patients in the emergency room, operation theatre, intensive care unit and trauma ward with an endeavour to provide best possible treatment for physical injuries. At the same time, it is equally important to give adequate attention to behavioural and psychological aspects associated with the event. Knowledge of the predisposing factors and their management helps the clinician to prevent or manage these psychological problems. Various causes of psychological disturbances in trauma patients have been highlighted. These include pain, the sudden and unexpected nature of events and the procedures and interventions necessary to resuscitate and stabilise the patient. The ICU and trauma ward environment, sleep and sensory deprivation, impact of injury on CNS, medications and associated pre-morbid conditions are also significant factors. Specific problems that concern the traumatised patients are helplessness, humiliation, threat to body image and mental symptoms. The patients react to these stressors by various defence mechanisms like conservation withdrawal, denial, regression, anger, anxiety and depression. Some of them develop delirium or even more severe problems like acute stress disorder or post-traumatic stress disorder. Physical, pharmacological or psychological interventions can be performed to prevent or minimise these problems in trauma patients. These include adequate pain relief, prevention of sensory and sleep deprivation, providing familiar surroundings, careful explanations and reassurance to the patient, psychotherapy and pharmacological treatment whenever required.

Tramadol for prevention of postanaesthetic shivering: a randomised double-blind comparison with pethidine

The present study was conducted with the aims of comparing intravenous tramadol 1, 2 and 3 mg.kg−1 with pethidine 0.5 mg.kg−1 for prophylaxis of postanaesthetic shivering and to find a dose of tramadol that could provide the dual advantage of antishivering and analgesic effect in the postoperative period. The study included 165 patients, randomly allocated to five groups of 33 each. Tramadol in doses of 1, 2 and 3 mg.kg−1, pethidine 0.5 mg.kg−1 or normal saline were administered at the time of wound closure. All three doses of tramadol were effective and comparable to pethidine in preventing postanaesthetic shivering. Tramadol 2 mg.kg−1 had the best combination of antishivering and analgesic efficacy without excessive sedation and thus appeared to be a good choice to be administered at the time of wound closure to provide antishivering effect and analgesia without significant side effects in the postoperative period.

Randomised trial of intravenous infusion of ephedrine or mephentermine for management of hypotension during spinal anaesthesia for Caesarean section

This study compared the effects of intravenous infusions of ephedrine and mephentermine for maintenance of maternal arterial pressure and neonatal outcome in pregnant women receiving subarachnoid block for lower segment Caesarean section. Sixty patients who developed hypotension following subarachnoid block for Caesarean section were randomly divided into two groups of 30 each to receive an intravenous infusion of ephedrine or mephentermine. Hypotension was defined as a decrease in systolic blood pressure of ≥ 20% from the baseline value or an absolute value of <100 mmHg, whichever was higher. The vasopressor infusion was titrated to maintain systolic blood pressure between ‘hypotension’ and baseline values. Baseline haemodynamic parameters, haemodynamic changes subsequent to the start of vasopressor infusion, duration of hypotension and amount of vasopressor required were statistically similar for both groups. Neonatal APGAR scores and acid‐base profiles were also comparable. To conclude, mephentermine can be used as safely and effectively as ephedrine for the management of hypotension during spinal anaesthesia in patients undergoing elective Caesarean section.

Efficacy of intrathecal adenosine for postoperative pain relief.

Background and objective: Adenosine, by intravenous and intrathecal routes, is known to alleviate various types of pain. However, the role of intrathecal adenosine in providing postoperative analgesia has not been confirmed. The aim of the present study was to evaluate the efficacy of intrathecal adenosine for postoperative pain relief, and to determine its role for pre‐emptive analgesia. Methods: Ninety ASA I and II females, undergoing elective abdominal hysterectomy, were randomly divided into three groups of 30 patients each. Patients in the ‘early adenosine’ group received intrathecal adenosine 1000 μg, 30 min before induction of anaesthesia. Patients in the ‘late adenosine’ group received the same dose before reversal of neuromuscular blockade. Control patients did not receive any test drug. A balanced general anaesthesia technique was used in all patients. Pain intensity scores using a visual analogue scale, sedation scores, time to first rescue analgesic and total morphine requirement were recorded. Results: There was no significant difference in pain intensity scores, sedation scores, total morphine requirements and time to first rescue analgesic among the three groups. Conclusion: Intrathecal adenosine 1000 μg is not effective as an analgesic for postoperative pain relief, and there is no pre‐emptive effect.

A comparison of pressure-controlled and volume―controlled ventilation for laparoscopic cholecystectomy

The potential advantages of pressure‐controlled over volume‐controlled ventilation during laparoscopic surgery have yet to be proven. We randomly assigned 42 patients with BMI < 30 kg.m−2 scheduled for laparoscopic cholecystectomy to receive either pressure‐ or volume‐controlled ventilation. Compared with volume‐controlled ventilation, pressure‐controlled ventilation resulted in a significant decrease in mean (SD) peak airway pressure at 10 min (20.4 (2.7) vs 24.0 (4.7) cmH2O, p = 0.004) and 30 min (20.7 (3.0) vs 23.9 (4.9) cmH2O, p = 0.015) and an increase in mean airway pressure at 10 min (10.5 (0.9) vs 9.6 (1.1) cmH2O, p = 0.007) and 30 min (10.5 (1.1) vs 9.6 (1.2) cmH2O, p = 0.016) after the start of surgery. Gas exchange and haemodynamic stability were similar. We conclude that pressure‐controlled ventilation is a safe alternative and offers some advantages to volume‐controlled ventilation during laparoscopic cholecystectomy in non‐obese patients.

Efficacy of dexamethasone pretreatment for alleviation of propofol injection pain

epiglottis/glottis/hypopharynx could not be seen and the straight end of the gum-elastic bougie was directed blindly and without resistance along the right posterior pharyngeal wall until the distal portion was 10 cm beyond the laryngopharynx. A size 5 ProSeal LMA was railroaded into position along its drain tube and the cuff inflated with 20 mL of air. Ventilation, however, was impossible with high airway pressures and airway obstruction. The proposed algorithm was followed, but the mechanical obstruction tests and recommended manoeuvres failed to solve the problem. Remembering that ‘whatever remains, however improbable, must be the truth’, the gum-elastic bougie was advanced and resistance was encountered after approximately 10 cm, indicating tracheal placement. The ProSeal LMA was rapidly exchanged for a tracheal tube, which passed easily along the bougie and provided unobstructed ventilation once the bougie was removed. The lowest SPO2 was 94% and there were no other problems. An alternative solution would have been to reinsert the bougie along the left posterior pharyngeal wall to reposition it in the oesophagus. Based on an audit of our experience with the gum-elastic bougie-guided technique during routine use, we estimate that the frequency of inadvertent tracheal placement is around 1 : 5000. In principle, inadvertent tracheal placement is more likely in the difficult airway scenario, as the hypopharynx may not been seen at laryngoscopy. The proposed algorithm has been modified to accommodate this rare but important scenario (Fig.).

Role of thoracic epidural block in improving post-operative outcome for septic patients: a preliminary report.

Background and objectives Sepsis is considered a relative contraindication for epidural blockade. Recent evidence indicates that thoracic epidural blockade may be of benefit during sepsis by improving gut perfusion. This study was planned to evaluate whether combining thoracic epidural blockade with general anaesthesia could decrease the post-operative mortality and morbidity in patients with sepsis due to perforation peritonitis. Methods This randomised non-blinded study included consenting adult patients of the American Society of Anesthesiologists grade II–III, undergoing emergency laparotomy for small intestinal perforation peritonitis. Severity of illness was evaluated using Mannheim Peritonitis Index, Acute Physiology and Chronic Health Evaluation III score and clinical indicators of systemic inflammatory response syndrome. Patients were randomised into two groups depending on the anaesthetic technique [general anaesthesia combined with thoracic epidural block (group GT) and general anaesthesia (group GA), n = 33 each. The thoracic block was extended from T5 to T10 using 0.125% bupivacaine in aliquots of 2–3 ml, with 50 μg fentanyl. Post-operatively, patients were followed for occurrence of any major morbidity till discharge from hospital, and 30-day mortality. ‘Major morbidity’ included development of organ failure. Post-operative markers for gut motility and perfusion, that is, time to passage of flatus, stools, resumption of oral feeds and occurrence of anastomotic leak were also observed. Sample size was calculated at power of 80% and α error of 0.05, aiming to detect a decrease of 50% in the incidence of post-operative major morbidity or mortality. Results Patients in the two groups were similar with respect to demographic profile and severity of sepsis. The number of patients with major morbidity or 30-day mortality were statistically similar between the two groups (group GT, 0/33; group GA 4/33; P = 0.114). A significantly shorter time to pass stools and resume oral feeds in group GT (4 ± 2 vs. 3 ± 1 days) (P = 0.006 and 0.012, respectively) and lesser incidence of anastomotic leak (0/33 vs. 4/33; P = 0.114) showed earlier recovery of gut motility and perfusion in that group. Conclusion Use of intra-operative segmental thoracic epidural blockade performed in addition to general anaesthesia suggested some benefit in improving post-operative mortality or major morbidity, but the trend was not significant, perhaps due to the small sample size. There was, however, a significantly earlier return of bowel motility and earlier discharge from hospital.

Epidural Volume Extension and Intrathecal Dose Requirement: Plain Versus Hyperbaric Bupivacaine

BACKGROUND: Epidural volume extension leads to an increase in sensory spread of local anesthetic, but whether this translates into lower dose requirements during combined spinal epidural (CSE) remains undetermined. Likewise, the influence of intrathecal drug baricity on the dose-sparing effect of epidural volume extension has not been investigated. We studied the dose-sparing effect of epidural volume extension and its relation to intrathecal drug baricity by comparing the ED50 of plain and hyperbaric bupivacaine with and without epidural volume extension. METHODS: Eighty-eight adult male patients scheduled for lower limb orthopedic surgery under CSE in the sitting position were randomized to four groups (n = 22 each); intrathecal injection was made with plain bupivacaine in groups plain bupivacaine (PB) and plain bupivacaine with epidural volume extension (PBE), and hyperbaric bupivacaine in groups hyperbaric bupivacaine (HB) and hyperbaric bupivacaine with epidural volume extension (HBE). Fentanyl, 25 &mgr;g, was added to the intrathecal drug in all groups. Among these four groups, epidural volume extension was performed with 10 mL normal saline only for groups PBE and HBE. The dose of spinal bupivacaine was varied using the up-and-down sequential allocation method. The first patient of each group received 10 mg bupivacaine. A successful spinal block was defined as attainment of sensory level of at least T10 along with complete motor blockade within 20 min of the intrathecal injection. The dose of bupivacaine was sequentially increased or decreased by 1 mg depending on whether spinal block was a failure or success in the previous patient. RESULTS: The addition of epidural volume extension to plain bupivacaine, i.e., group PBE versus group PB, resulted in a significant decrease in ED50 (relative potency estimate: 1.2, 95% CI: 1.04–1.64) and increase in maximum sensory level (T6 vs T8, respectively, P < 0.05). These differences were not seen with hyperbaric bupivacaine (group HB vs HBE). Independent of the effect of epidural volume extension, the ED50 of plain bupivacaine when compared with hyperbaric bupivacaine was significantly lower (relative potency estimate of group PB vs group HB: 0.78, 95% CI: 0.54–0.93; and for group PBE vs group HBE: 0.68, 95% CI: 0.37–0.87). CONCLUSIONS: Administered with or without epidural volume extension, plain bupivacaine appears to be more effective, requiring a smaller dose and producing a higher sensory block with an earlier onset in comparison to hyperbaric bupivacaine. Epidural volume extension, when applied to intrathecal hyperbaric bupivacaine, fails to decrease the dose or raise the level of block.

Single-shot spinal anaesthesia, combined spinal-epidural and epidural volume extension for elective caesarean section: a randomized comparison

BACKGROUND Single-shot spinal and combined spinal-epidural block, with or without epidural volume extension, can be used for caesarean section. There is no trial comparing their block characteristics and adverse effects under identical conditions. METHODS 60 ASA I or II parturients with gestational age 37 weeks or more, scheduled for elective caesarean section under regional anaesthesia, were included in the trial. Women were randomized to three groups: group SSS: single-shot spinal; group CSE: combined spinal-epidural; group EVE: epidural volume extension of a combined spinal-epidural. Intrathecal injection was identical in the three groups (0.5% hyperbaric bupivacaine 9 mg with fentanyl 10 microg) and was injected via a 25-gauge pencil-point spinal needle, either as a single-shot spinal or through the spinal needle of the needle-through-needle CSE set. In group EVE, 5 mL of normal saline was injected through the epidural catheter. All blocks were performed with the women sitting. Haemodynamic parameters and block characteristics were assessed. RESULTS The onset of maximum sensory and motor block was significantly faster in the SSS group than in the other two. Extent and duration of sensory and motor block and the incidence of adverse effects were similar in the three groups (P>0.05). CONCLUSIONS Intrathecal block is similar in extent and duration whether given as a single-shot spinal or a combined spinal-epidural with or without epidural volume extension when performed for elective caesarean section using hyperbaric bupivacaine in the sitting position.