N Krishnaveni

A comparative study of nerve stimulator versus ultrasound-guided supraclavicular brachial plexus block

Introduction: With the advent of ultrasound (US) guidance, this technique saw resurgence in the late 1990s. As US guidance provides real-time view of the block needle, the brachial plexus, and its spatial relationship to the surrounding vital structures; it not only increased the success rates, but also brought down the complication rates. Most of the studies show use of US guidance for performing brachial plexus block, results in near 100% success with or without complications. This study has been designed to examine the technique and usefulness of state-of-the-art US technology-guided supraclavicular brachial plexus block and compare it with routine nerve stimulator (NS)-guided technique. Aim: To note block execution time, time of onset of sensory and motor block, quality of block and success rates. Settings and Design: Randomized controlled trial. Materials and Methods: A total of 60 patients were enrolled in this prospective randomized study and were randomly divided into two groups: US (Group US) and NS (Group NS). Both groups received 1:1 mixture of 0.5% bupivacaine and 2% lignocaine with 1:200000 adrenaline. The amount of local anaesthetic injected calculated according to the body weight and not crossing the toxic dosage (Inj. bupivacaine 2 mg/kg, Inj. lignocaine with adrenaline 7 mg/kg). The parameters compared between the two groups are block execution time, time of onset of sensory and motor block, quality of sensory and motor block, success rates are noted. The failed blocks are supplemented with general anesthesia. Statistical Analysis: The data were analyzed using the SPSS (version 19) software. The parametric data were analyzed with student “t” test and the nonparametric data were analyzed with Chi-square test A P < 0.05 was considered significant. Results: There was no significant difference between patient groups with regard to demographic data, the time of onset of sensory and motor block. Comparing the two groups, we found that the difference in the block execution time and success rates is not statistically significant. A failure rate of 10% in US and 20% in NS group observed and is statistically insignificant (P = 0.278). No complication observed in either group. Conclusions: US and NS group guidance for performing supraclavicular brachial plexus blocks ensures a high success rate and a decreased incidence of complications that are associated with the blind technique. However, our study did not prove the superiority of one technique over the other. The US-guided technique seemed to have an edge over the NS-guided technique. A larger study may be required to analyze the advantages of using US in performing supraclavicular brachial plexus blocks, which could help justify the cost of purchase of the US machine.

A comparative study between Truview PCD laryngoscope and Macintosh laryngoscope in viewing glottic opening and ease of intubation: A crossover study

Background: TruviewPCD laryngoscope is specially designed to aid positioning of the endotracheal tube as well as to record entry of the tube into glottis. Aim of the study is to compare the view of glottic opening and ease of intubation between TruviewPCD laryngoscope and Macintosh laryngoscope in patients undergoing general anesthesia (GA). Methodology: Two hundred patients undergoing elective surgery, under GA were randomized into two groups, Group TV and Group ML. In Group TV, TrueviewPCD laryngoscope was used initially to visualize the vocal cords for Cormack and Lehane grading (CLG) and to spray the vocal cords with 10% lignocaine. Then the patient was ventilated for 1 min and Macintosh laryngoscope was used to visualize the vocal cords for CLG and proceed with intubation. In Group ML, Macintosh laryngoscope was used initially and later TruviewPCD laryngoscope. Time to intubation, CLG, number of attempts and hemodynamic parameters were recorded. Results: Ninety-six and 89 patients had CLG1 visualization when TruviewPCD laryngoscope was used as 1st and 2nd device respectively compared to 41 and 68 with Macintosh laryngoscope (P = 0.00). Four patients had CLG 4 visualization with Macintosh laryngoscope that turned out to be grade II visualization with TruviewPCD laryngoscope (P = 0.00). Mean time taken for intubation with TruviewPCD and Macintosh laryngoscope was 21.10 ± 5.64 s and 15.79 ± 2.76 s respectively (P = 0.00). Conclusion: Better visualization with lesser CLG was found with TruviewPCD laryngoscope but it took longer time for intubation than Macintosh laryngoscope. The hemodynamic response to intubation was significantly less with the use of TruviewPCD laryngoscope when compared to that of Macintosh laryngoscope.

Relative efficacy of ultrasound-guided ilioinguinal-iliohypogastric nerve block versus transverse abdominis plane block for postoperative analgesia following lower segment cesarean section: A prospective, randomized observer-blinded trial

Background: Quality of postoperative analgesia after cesarean section makes difference to mother in child bonding, early ambulation, and discharge. Ilioinguinal iliohypogastric (ILIH) and transverse abdominis plane (TAP) block had been tried to reduce the opioid analgesics, but the relative efficacy is unknown. Hence, this study was designed to compare the efficacy of these two regional analgesic techniques in sparing postoperative rescue analgesic requirement following lower segment cesarean section (LSCS). Methods: Sixty patients who underwent LSCS were randomly allocated into two groups to receive either US-guided TAP block or ILIH nerve block using sealed envelope technique at the end of the surgery. In the postoperative ward, whenever patient complained of pain, pain nurse in-charge administered the rescue analgesics as per the study protocol. A blinded observer visited the patient at 0, 2, 4, 6, 8, 10, 12, and 24 h postoperative intervals and recorded the quality of pain relief and the amount of rescue analgesic consumed. Results: All patients in both the study groups required one dose of rescue analgesics in the form of injection diclofenac sodium 50 mg intravenously but subsequently 57% of patients did not require any further analgesics till 24 h in the TAP block group whereas in ILIH group, only 13% did not require further analgesics (P = 0.00), correspondingly the cumulative tramadol dose was significantly higher at all the time interval in the ILIH group when compared to the TAP group. Conclusion: Quality of postoperative analgesia provided by TAP block was superior to ILIH block following LSCS.

A comparative study of postoperative analgesia provided by ultrasound-guided transversus abdominis plane block using two concentrations of bupivacaine in patients undergoing inguinal hernia repair

Background: Pain after open inguinal hernia surgery can be moderate to severe and is known to prolong hospital stay and delay return to normal daily activities. Settings: A randomized controlled trial conducted in the Department of Anesthesiology in a tertiary care hospital. Aims and Objectives: To compare the efficacy of postoperative analgesia provided by equal volumes of 0.125% and 0.25% bupivacaine administered in an ultrasound (US)-guided transversus abdominis plane (TAP) block in patients undergoing unilateral inguinal hernia repair. Materials and Methods: After obtaining Institutional Ethics Committee approval and informed consent, sixty patients posted for inguinal hernia repair were recruited. Randomization was done using a sealed envelope technique. Patients were divided into two groups; Group 0.125 received 20 ml of 0.125% bupivacaine and Group 0.25 received 20 ml of 0.25% bupivacaine through US-guided TAP block at the end of surgery. Visual analog scale (VAS) scores and duration of analgesia were recorded. Results: There was no significant difference in the VAS scores among both groups. The duration of analgesia provided by 0.25% bupivacaine was significantly longer than that provided by 0.125% (Group 0.125 - 355.67 ± 118.88 min and Group 0.25 - 635.73 ± 195.58 min; P < 0.05). No complications were noted in both groups. Conclusion: The duration of analgesia provided by 0.25% bupivacaine was significantly longer than that provided by 0.125% bupivacaine through US-guided TAP block in inguinal hernia repair.

Evaluating the efficacy of tramadol as an adjuvant to intrathecal isobaric levobupivacaine for elective infraumbilical surgeries

Background: Long-acting local anesthetics are used in subarachnoid block to increase the duration of anesthesia. Adjuvants are added to improve the duration of analgesia. Settings: Randomized controlled trial was conducted in the Department of Anesthesiology in a tertiary care hospital.Aims and Objectives: The objective of this study was to evaluate the efficacy of low-dose tramadol as an intrathecal adjuvant to levobupivacaine in terms of duration of analgesia, onset of sensory blockade, onset of motor blockade, and duration of motor blockade. Methodology: After obtaining the Institutional Ethics Committee approval and informed consent, sixty patients posted for infraumbilical surgeries were recruited. Randomization was done using a sealed envelope technique. Patients were divided into two groups: LT received 3 ml of 0.5% isobaric levobupivacaine with tramadol 10 mg (0.2 ml) and LS received 3 ml of 0.5% isobaric levobupivacaine with 0.2 ml of normal saline. Duration of analgesia, onset of sensory blockade, and onset and duration of motor blockade were recorded. Results: There was no statistical difference in demographic data between the two groups. The mean onset time of sensory blockade in Group LS was 12.7 ± 9.81 min and for Group LT was 12.9 ± 0.81 min, which was not statistically significant between two groups (P = 0.93). The mean onset time of motor blockade in Group LS was 13.4 ± 10 min and for Group LT was 14.4 ± 10 min, which was no statistically significant between the two groups (P = 0.71). The mean time duration of analgesia in Group LS was 170.3 ± 59 min and for LT was 198.9 ± 57.33 min. There was mild prolongation of analgesia in Group LT, but it was not statistically significant (P = 0.0615). The mean duration of motor blockade in Group LS was 170.23 ± 58 min and Group LT was 190.76 ± 4 min, which was not statistically significant between the two groups (P = 0.14). Conclusion: Low-dose tramadol as an adjuvant to isobaric intrathecal levobupivacaine does not prolong analgesia significantly.

Efficacy of tramadol or dexamethasone as an adjuvant to levobupivacaine in ultrasound-guided supraclavicular plexus block for upper limb surgery: A randomized double-blinded controlled study

Aims and Objectives: To evaluate the efficacy of tramadol or dexamethasone as an adjuvant to levobupivacaine in ultrasound-guided supraclavicular brachial plexus block in terms of onset time of complete sensory and motor blockade, duration of motor blockade, duration of analgesia, and any complication. Settings and Design: This was a randomized controlled trial conducted in the Department of Anesthesiology, a tertiary care hospital. Materials and Methods: Sixty consecutive patients of the American Society of Anesthesiologists physical status Class I and II who were posted for upper limb surgeries were recruited. Patients were divided into two groups of thirty patients each. Group T (tramadol) received 20 ml of 0.5% levobupivacaine with 100 mg tramadol, and Group D (dexamethasone) received 20 ml of 0.5% levobupivacaine with 8 mg dexamethasone under ultrasound guidance. Sensory and motor block assessment was done every 2 min until the development of complete sensory and motor block till 45 min. Verbal numerical rating scale score was assessed in postoperative ward at regular intervals. Patients were followed up to check for any residual neurological deficits. Results: There was no statistical difference in demographic data between the two groups. The onset time of sensory and motor blockade shows no significant difference between groups. The mean time duration of motor blockade in Group T was 764.63 min and for Group D was 1150.27 min which was statistically significant (P < 0.05). The duration of analgesia in Group D was 1300.83 min and in Group T was 820.47 min which was statistically significant (P < 0.05). Side effects such as nausea, vomiting, pruritis, hypoxemia, and long-term neurological deficits were not reported in any of the patients in either group. Conclusion: Dexamethasone 8 mg as an adjuvant to 0.5% levobupivacaine for supraclavicular brachial plexus block using ultrasound guidance increases the duration of analgesia in comparison to 100 mg tramadol and provides excellent postoperative pain-free period without any neurological deficits.

Anesthetic management of intestinal obstruction: A postgraduate educational review

Intestinal obstruction is associated with significant morbidity and mortality. Scientific assessment of the cause, site of obstruction, appropriate correction of the fluid deficit and electrolyte imbalance with preoperative stabilization of blood gases is ideal as a preoperative workup. Placement of a preoperative epidural catheter especially in the thoracic interspace takes care of perioperative pain and stress reduction. Intraoperative management by controlled general anesthesia administering a relative high inspired fraction of oxygen with invasive monitoring in selected sick cases is mandatory. Preoperative monitoring and stabilizing raised intra-abdominal pressure reduces morbidity. Caution should be exercised during opening and closure of abdomen to avoid cardiorespiratory ill effects. There should be an emphasis on avoiding hypothermia. The use of nonsteroidal anti-inflammatory drugs may worsen sick, fragile patients. The use of sugammadex rather than neostigmine will obscure certain controversies in the healing of intestinal anastomotic site. Replacement of blood loss continued correction of fluids and electrolytes with possible postoperative mechanical ventilation in sick cases may improve outcomes in these patients.

Assessment of airway the MOUTH concept.

kg of propofol and 0.2 mcg/kg Department of Anesthesiology and Intensive Care, of sufentanilwere administered intravenously (IV) for induction of GA. The patient has been ventilated twice by facemask and trachea immediately intubated. Anesthesiawas maintainedwith nitrousoxide50%in oxygenand sevoflurane. In postanesthesia care unit, a left peripheral facial paralysis was noted. An emergent brain computed tomography (CT) scan was normal. Oral prednisolone was introduced after neurologist’s assessment. The patient was discharged on day 2. One year after, hemifacial spasms and synkinesis were still observed.A 47-year-old woman 2.presented with a postcoital headache with loss of consciousness. A brain CT scan revealed a subarachnoid hemorrhage (ruptured basilar artery aneurysm). On emergency, an external ventricular drain was inserted and aneurysm was occluded by coiling. Patient’s trachea was extubated on day 10. Right labial herpes lesions appeared on day 21 and were treated by topical application of acyclovir. Five days after, a ventriculoperitoneal shunt was inserted because of a persistent hydrocephalus. Induction of GA was performed with propofol (2.5 mg/kg), sufentanil (0.3 mcg/kg) and cisatracurium (0.15 mg/kg) IV. The patient’s lungs was ventilated by facemask and trachea intubated without difficulty. Anesthesia was maintained with sevoflurane without nitrous oxide. After tracheal extubation, a right peripheral nerve palsy was noted. Intravenous acyclovir and methylprednisolone were administered for 10 days. Six months later, a severe facial palsy was still present.These cases are highly suggestive of associations between IFP and GA.In demyelinating disorders, such as multiple sclerosis, GA has been implicated in causing disease exacerbation.