Nidhi Bhatia

Comparison of posterior and subcostal approaches to ultrasound-guided transverse abdominis plane block for postoperative analgesia in laparoscopic cholecystectomy

STUDY OBJECTIVE To evaluate the effectiveness of subcostal TAP block and to compare its efficacy with that of posterior TAP block in decreasing postoperative pain in patients undergoing laparoscopic cholecystectomy during general anesthesia. DESIGN Prospective, randomized, double-blind study. SETTING Academic medical center. PATIENTS 60 adult, ASA physical status 1 and 2 patients of both genders, aged 18-60 years, scheduled for elective laparoscopic cholecystectomy. INTERVENTIONS Patients were randomized to three groups of 20 patients each. Group 1 patients received standard general anesthesia (control group); Group 2 patients received an ultrasound-guided posterior TAP block using 15 mL of 0.375% ropivacaine on each side; and Group 3 patients underwent a subcostal TAP block with 15 mL of 0.375% ropivacaine on each side. MEASUREMENTS The presence and severity of pain during rest and movement, as well as nausea or vomiting and sedation, were assessed in all patients postoperatively on PACU admission, then at 2, 4, 6, 8, 12, and 24-hour intervals. Patients with a visual analog score (VAS) greater than 4, or those requesting analgesic were given intravenous tramadol 2 mg/kg as an initial dose; subsequent 1 mg/kg doses of tramadol, if needed, were given. RESULTS Patients who received a subcostal TAP block had significantly lower pain scores at rest and on movement than the control group at all times postoperatively. Although, in the initial postoperative measurement times, the subcostal and posterior TAP groups had comparable pain scores, after 4 hours these scores were significantly lower in patients who had received the subcostal TAP block. CONCLUSION For incisions mainly involving the supra-umbilical region, subcostal TAP block may be a better alternative than the posterior approach for providing postoperative analgesia.

Cricoid pressure: Where do we stand?

In 1961, Sellick popularized the technique of cricoid pressure (CP) to prevent regurgitation of gastric contents during anesthesia induction. In the last two decades, clinicians have begun to question the efficacy of CP and therefore the necessity of this maneuver. Some have suggested abandoning it on the grounds that this maneuver is unreliable in producing midline esophageal compression. Moreover, it has been found that application of CP makes tracheal intubation and mask ventilation difficult and induces relaxation of the lower esophageal sphincter. There have also been reports of regurgitation of gastric contents and aspiration despite CP. Further, its effectiveness has been demonstrated only in cadavers; therefore, its efficacy lacks scientific validation. These concerns with the use of CP in modern anesthesia practice have been briefly reviewed in this article.

Effect of intramucosal infiltration of different concentrations of adrenaline on hemodynamics during transsphenoidal surgery.

Background and Aims: Neurosurgeons routinely instill vasopressors, with or without local anesthetics, to prepare nasal passages prior to transsphenoidal surgeries. As there is a paucity of data comparing the effect of intramucosal nasal infiltration of different concentrations of adrenaline that is, 1:200,000 and 1:400,000 in patients undergoing transsphenoidal surgery, we conducted this study to evaluate the effect of these two concentrations of adrenaline with 2% lignocaine on hemodynamics as well as bleeding. Materials and Methods: Fifty-two American Society of Anesthesiologists I/II patients, aged 15-70 years, undergoing transsphenoidal surgery for pituitary or sellar masses were enrolled. Prior to surgical incision, nasal septal mucosa was infiltrated with lignocaine-adrenaline solution, after randomly allocating them to one of the two groups, with patients in Group A receiving intramucosal infiltration using 2% lignocaine with 1:200,000 adrenaline and those in Group B receiving 2% lignocaine with 1:400,000 adrenaline. Following infiltration, hemodynamic parameters were recorded every 1 min for 5 min and thereafter at every 5 min interval. Results: Fewer patients (3/24 [12.5%]) in Group B had a rise of >50% in systolic blood pressure, from baseline values, after nasal mucosa infiltration as compared with patients in Group A (9/24 [37.5%]). In addition, mean rise in systolic, diastolic and mean arterial pressure was also significantly lower in Group B as compared with Group A. Conclusion: Adrenaline in a concentration of 1:400,000 added to 2% lignocaine for nasal mucosa infiltration produces less hemodynamic response as compared with adrenaline 1:200,000 added to 2% lignocaine while at the same time providing similar operating conditions.

Evaluation of analgesic effect of local administration of morphine after iliac crest bone graft harvesting: A double blind study

Background and Objective: Pain is a complex process influenced by both physiological and psychological factors. In spite of an armamentarium of analgesic drugs and techniques available to combat post-operative pain, appropriate selection, and effective management for relief of post-operative pain still poses unique challenges. The discovery of peripheral opioid receptors has led to growing interest in the use of locally applied opioids (intra-articular, intra-pleural, intra-peritoneal, and perineural) for managing acute pain. As bone graft harvesting is associated with significant post-operative pain and there is a paucity of literature on the use of peripheral opioids at the iliac crest bone harvesting site, the present study was planned to evaluate the analgesic efficacy of local administration of morphine after iliac crest bone graft harvesting. Materials and Methods: A total of 60 patients, 20-50 years of age scheduled to undergo elective surgery for delayed and non-union fracture both bone leg with bone grafting under general anaesthesia (GA) were randomly assigned to one of the four groups of 15 patients each: group 1: 2.5 ml normal saline (NS) +2.5 ml NS infiltrated into the harvest site at 2 sites + 1 ml NS intramuscularly (i/m); Group 2: 2.5 ml NS + 2.5 ml NS infiltrated into the harvest site at 2 sites + 5 mg morphine in 1 ml i/m.; Group 3: 2.5 mg (2.5 ml) morphine + 2.5 mg (2.5 ml) morphine infiltrated into the harvest site at 2 sites + 1 ml NS i/m; Group 4: 0.5 mg naloxone (2.5 ml) +5 mg (2.5 ml) morphine infiltrated into the harvest site at 2 sites + 1 ml NS i/m. Pain from the bone graft site and operative site was assessed for 24 h post-operatively. Results: The patients who had received morphine infiltration (Group 3) had significantly less pain scores at the graft site at 4, 6, and 10 post-operative hours. They also had significantly less morphine consumption and overall better pain relief as compared to the other groups. Conclusions: Morphine administered peripherally provided better analgesia as compared to that given systemically and this effect was noticeable after 4 h post-operatively.

Comparison of oral midazolam with intranasal dexmedetomidine premedication for children undergoing CT imaging: a randomized, double-blind, and controlled study

Children undergoing computerized tomography (CT) frequently require sedation to allay their anxiety, and prevent motion artifacts and stress of intravenous (IV) cannulation.

Endotracheal intubation through the intubating laryngeal mask airway (LMA-Fastrach™): A randomized study of LMA- Fastrach™ wire-reinforced silicone endotracheal tube versus conventional polyvinyl chloride tracheal tube

Context: A wire-reinforced silicone tube (LMA-Fastrach™ endotracheal tube) is specially designed for tracheal intubation using intubating laryngeal mask airway (ILMA). However, conventional polyvinyl chloride (PVC) tracheal tubes have also been used with ILMA to achieve tracheal intubation successfully. Aim: To evaluate the success of tracheal intubation using the LMA-Fastrach™ tracheal tube versus conventional PVC tracheal tube through ILMA. Settings and Design: Two hundred adult ASA physical status I/II patients, scheduled to undergo elective surgery under general anaesthesia requiring intubation, were randomly allocated into two groups. Methods: The number of attempts, time taken, and manoeuvres employed to accomplish tracheal intubation were compared using conventional PVC tubes (group I) and LMA-Fastrach™ wire-reinforced silicone tubes (group II). Intraoperative haemodynamic changes and evidence of trauma and postoperative incidence of sore throat and hoarseness, were compared between the groups. Statistical Analysis: The data was analyzed using two Students t test and Chi-square test for demographics and haemodynamic parameters. Mann Whitney U test was used for comparison of time taken for endotracheal tube insertion. Fishers exact test was used to compare postoperative complications. Results: Rate of successful tracheal intubation and haemodynamic variables were comparable between the groups. Time taken for tracheal intubation and manoeuvres required to accomplish successful endotracheal intubation, however, were significantly greater in group I than group II (14.71±6.21 s and 10.04±4.49 s, respectively (P<0.001), and 28% in group I and 3% in group II, respectively (P<0.05)). Conclusion: Conventional PVC tube can be safely used for tracheal intubation through the ILMA.

Ultrasound-guided single- vs double-level thoracic paravertebral block for postoperative analgesia in total mastectomy with axillary clearance☆☆☆

OBJECTIVES Thoracic paravertebral block (TPVB) for breast surgery reduces acute and chronic postoperative pain. Using ultrasound for administering the block makes it easier, with its administration at multiple levels decreasing the number of unblocked segments. We conducted this study to evaluate the efficacy and safety of single- vs double-level ultrasound-guided TPVB in patients undergoing total mastectomy with axillary clearance under general anesthesia. DESIGN This is a prospective, randomized study. SETTING Recovery room and operation theater. PATIENTS Sixty ASA I and II patients, aged 18 to 60 years, who were scheduled to undergo total mastectomy with axillary clearance under general anesthesia were enrolled in the study. INTERVENTIONS Patients received either single- (group S) or double-level (group D) ultrasound-guided TPVB at T4 or at T2 and T5 levels, respectively, using 0.3 mL/kg of 0.5% ropivacaine. MEASUREMENTS Primary outcome measure was 24-hour analgesic consumption, and secondary outcomes included number of segments blocked, postoperative pain scores, time to first request for rescue analgesic, and any side effects. RESULTS The mean total amount of rescue analgesic given in group S was 175.3 ± 70 mg and in group D was 115.7 ± 48 mg (P = .002). Median number of segments showing less sensation to pinprick was 3 in group S and 4 in group D (P < .001). The mean time to first request for rescue analgesic was 533 ± 124 minutes in group S and was 611 ± 214 minutes in group D (P = .118). CONCLUSION Patients receiving double-level TPVB had significantly less 24-hour analgesic consumption in the postoperative period than those in the single-level TPVB group. This could be due to decreased pain sensation to pinprick in significantly greater number of segments in the double-level TPVB group.

Postoperative analgesic efficacy of ultrasound-guided ilioinguinal-iliohypogastric nerve block compared with medial transverse abdominis plane block in inguinal hernia repair: A prospective, randomised trial

PURPOSE Analgesic efficacy of ultrasound-guided transverse abdominis plane block, administered a little more medially, just close to the origin of the transverse abdominis muscle has not yet been investigated in patients undergoing unilateral inguinal hernia repair. We hypothesised that medial transverse abdominis plane block would provide comparable postoperative analgesia to ilioinguinal-iliohypogastric nerve block in inguinal hernia repair patients. METHODS This prospective, randomised trial was conducted in 50 ASA I and II male patients≥18 years of age. Patients were randomised into two groups to receive either pre-incisional ipsilateral ultrasound-guided ilioinguinal-iliohypogastric nerve block or medial transverse abdominis plane block, with 0.3ml/kg of 0.25% bupivacaine. Our primary objective was postoperative 24-hour analgesic consumption and secondary outcomes included pain scores, time to first request for rescue analgesic and side effects, if any, in the postoperative period. RESULTS There was no significant difference in the total postoperative analgesic consumption [group I: 66.04mg; group II: 68.33mg (P value 0.908)]. Time to first request for rescue analgesic was delayed, though statistically non-significant (P value 0.326), following medial transverse abdominis plane block, with excellent pain relief seen in 58.3% patients as opposed to 45.8% patients in ilioinguinal-iliohypogastric nerve block group. CONCLUSION Medial transverse abdominis plane block being a novel, simple and easily performed procedure can serve as an useful alternative to ilioinguinal-iliohypogastric nerve block for providing postoperative pain relief in inguinal hernia repair patients.

Ultrasound guided superior laryngeal nerve block as an adjuvant to generalanesthesia during endoscopic laryngeal surgery: A prospective, randomized, double-blind trial

INTRODUCTION Blindly administered bilateral (B/L) superior laryngeal nerve (SLN) blocks, have been used to decrease the perioperative stress response of endoscopic laryngosurgeries. Use of ultrasound (USG) for giving these blocks is more likely to be successful, with fewer complications. We evaluated the efficacy of USG guided B/L SLN block in decreasing perioperative cough, sore-throat and hoarseness of voice. MATERIAL AND METHODS This study was conducted on forty patients undergoing endoscopic laryngosurgery under GA. Patients were randomized into two groups of 20 patients each. Patients in group C received GA, whereas those in group L received USG-guided SLN block bilaterally with 2.5 ml of 2% lignocaine, along with GA. Postoperative cough, sore throat and hoarseness of voice was measured at 30 min, 2 h, 4 h and 24 h following transfer to post-anesthesia care unit. RESULTS Patients receiving SLN block had significantly lower incidence of perioperative cough (20% in group L vs 90% in group C; p value - 0.0001) as well as sore throat (5% in group L vs 95% in group C; p value - 0.0001). In these patients, severity of hoarseness of voice was greater in the early postoperative period (100% in group L vs 70% in group C; p value - 0.027), while it decreased significantly at 24 h postoperatively(0.0% in group L vs 30% in group C; p value - 0.027). CONCLUSION USG guided SLN block as an adjuvant to GA resulted in better recovery profile of the patients with significant reduction in postoperative cough, sore throat and hoarseness of voice.

Eficácia da pré-oxigenação usando respiração em volume corrente: uma comparação dos sistemas Mapleson A, Bain e Circular

BACKGROUND Efficacy of preoxygenation depends upon inspired oxygen concentration, its flow rate, breathing system configuration and patient characteristics. We hypothesized that in actual clinical scenario, where breathing circuit is not primed with 100% oxygen, patients may need more time to achieve EtO2≥90%, and this duration may be different among various breathing systems. We thus studied the efficacy of preoxygenation using unprimed Mapleson A, Bains and Circle system with tidal volume breathing at oxygen flow rates of 5L.min-1 and 10L.min-1. METHODS Patients were randomly allocated into one of the six groups, wherein they were preoxygenated using either Mapleson A, Bains or Circle system at O2 flow rate of either 5L.min-1 or 10L.min-1. The primary outcome measure of our study was the time taken to achieve EtO2≥90% at 5 and 10L.min-1 flow rates. RESULTS At oxygen flow rate of 5L.min-1, time to reach EtO2≥90% was significantly longer with Bains system (3.7±0.67min) than Mapleson A and Circle system (2.9±0.6, 3.3±0.97min, respectively). However at oxygen flow rate of 10L.min-1 this time was significantly shorter and comparable among all the three breathing systems (2.33±0.38min with Mapleson, 2.59±0.50min with Bains and 2.60±0.47min with Circle system). CONCLUSIONS With spontaneous normal tidal volume breathing at oxygen flow rate of 5L.min-1, Mapleson A can optimally preoxygenate patients within 3min while Bains and Circle system require more time. However at O2 flow rate of 10L.min-1 all the three breathing systems are capable of optimally preoxygenating the patients in less than 3min.