Rajeshwari Subramaniam

Prophylactic Dexamethasone for Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Dose Ranging and Safety Evaluation Study

In this double-blind, randomized, placebo-controlled study, we evaluated the efficacy and safety of different doses of prophylactic IV dexamethasone for postoperative nausea and vomiting (PONV) in 168 children (aged 2–15 yr) scheduled for strabismus surgery. Patients received IV dexamethasone 0.25 mg/kg (D 0.25), 0.5 mg/kg (D 0.5), 1.0 mg/kg (D 1), or saline (S) immediately after induction of general anesthesia. Patients were discharged 24 h after surgery. Nausea and vomiting were assessed at 0–2, 2–6, and 6–24 h after surgery. Blood glucose was measured preoperatively and at 4 h after study drug administration. Wound healing and infection were assessed after 1 wk. More patients in group S had vomiting at 0–2, 2–6, and 6–24 h (P = 0.001, P = 0.003, and P = 0.04, respectively) and required larger doses of rescue antiemetics compared with the dexamethasone groups. Fewer patients in the dexamethasone groups (6, 3, and 6 in D 0.25, D 0.5, and D 1, respectively) had severe PONV compared with group S (P = 0.001). No significant increase in postoperative blood glucose levels was observed and wound healing was satisfactory in all four groups. The results suggest that dexamethasone 0.25 mg/kg is more effective than saline and equally effective compared with larger doses for preventing PONV for pediatric strabismus surgery.

Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery.

Methods: Fifty children (age 5–14 years, ASA I–II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique.

Usefulness of pre-emptive peribulbar block in pediatric vitreoretinal surgery: A prospective study

Background and Objectives Vitreoretinal (VR) surgery with or without scleral buckling is associated with significant postoperative pain and emesis in adults, and recent studies have addressed the effect of retro or peribulbar block on these parameters. VR surgery in children has received little attention regarding the incidence of pain and emesis, and the role of regional anesthesia in modifying these parameters. In this study, we compared peribulbar block with conventional opioid analgesia in children undergoing VR surgery. Methods In a prospective, randomized, single-blind study, 85 children (ages 6 to 13 years) were allocated to receive peribulbar block (n = 42) or intravenous meperidine 1 mg/kg (n = 43) after induction of general anesthesia. Parameters compared were: intraoperative incidence of oculocardiac reflex and requirement for additional analgesic; postoperative pain intensity; incidence of postoperative emesis; time to first analgesic, total number of postoperative analgesic supplements; and parental assessment of the child’s postoperative comfort at 24 hours. Results The incidence of intraoperative oculocardiac reflex was significantly less in the peribulbar group (P = .0001). Significantly more children receiving peribulbar block were pain free on awakening (P = .0004) and throughout the postoperative period. The number of children requiring opioid was significantly lower with peribulbar block (P = .008), and a significant number of children did not vomit throughout the postoperative period (P = .001). Conclusions Peribulbar block appears to be a safe and clinically superior alternative to intravenous opioid for pediatric VR surgery. Reg Anesth Pain Med 2003;28:43-47.

Anesthetic techniques and postoperative emesis in pediatric strabismus surgery

Background and Objectives: Postoperative emesis after pediatric strabismus surgery continues to be a problem, despite the use of antiemetics. The purpose of this study was to identify an anesthetic technique associated with the lowest incidence of vomiting after pediatric strabismus surgery. Methods: A prospective, randomized, double-blind study was conducted to evaluate the effect of intravenous fentanyl, meperidine, or peribulbar block with propofol infusion on emesis in 105 pediatric patients undergoing strabismus surgery. Anesthesia was maintained with nitrous oxide, oxygen, and propofol infusion. Ketorolac 1.0 mg/kg−1 intramuscular was administered to all patients after induction. Patients were given either a peribulbar block, intravenous fentanyl 2 μg/kg−1, or intravenous meperidine 1mg/kg−1 for perioperative analgesia. The emesis scores were observed for the first 24 hours postoperatively. Results: The incidence of emesis was significantly lower (1 of 35; 2.9%) in the peribulbar group compared with the meperidine group (9 of 35; 25.6%) (P < .01) in the first 24 hours. The fentanyl group had a higher incidence of postoperative vomiting (4 of 35; 11.4%) than did the peribulbar group; the difference, however, was not statistically significant. Conclusion: Among the three techniques, peribulbar block with propofol-based anesthesia is the technique with the lowest incidence of postoperative emesis. Fentanyl-propofol is an equally acceptable alternative; however, meperidine-propofol is associated with a high incidence of postoperative emesis.

Comparison of sub-Tenon's block with i.v. fentanyl for paediatric vitreoretinal surgery

BACKGROUND Vitreoretinal (VR) surgery is associated with moderate to severe pain and significant postoperative nausea and vomiting (PONV). The study aimed to assess the effectiveness of sub-Tenons block for providing perioperative analgesia in children undergoing VR surgery. METHODS In a randomized, observer-blinded trial, after obtaining institutional ethical committee approval and parental consent, 200 ASA grade I-II children aged 5-16 yr were allocated to receive either a sub-Tenons block (Group SB) or 2 microg kg(-1) i.v. fentanyl (Group F) after induction of anaesthesia and topical anaesthesia of the conjunctiva with proparacaine 0.5% drops. Patients in Group F received fentanyl 0.5 microg kg(-1) and those in Group SB were given a corresponding volume of normal saline i.v. every hour from preloaded syringes. Increases in heart rate or mean arterial pressure by more than 20% of baseline were treated with additional 0.5 microg kg(-1) i.v. fentanyl boluses in both groups. The incidence of oculocardiac reflex (OCR), need for additional analgesics, postoperative pain, and PONV were recorded for the first 24 h after surgery. RESULTS More patients in Group F (47.96%) had moderate to severe pain in the first 24 h when compared with Group SB (31.36%) (P=0.023). The need for postoperative ibuprofen was higher in Group F (66.3%) compared with Group SB (47.95%) (P=0.012). The incidence of OCR was significantly higher in Group F (31.6%) compared with Group SB (5.1%) (P<0.001). The incidence of PONV was similar in both groups. CONCLUSIONS Sub-Tenons block provides more effective analgesia than i.v. fentanyl for paediatric VR surgery.

Transversus abdominis plane block for laparoscopic inguinal hernia repair: a randomized trial

BACKGROUND Pain after laparoscopic inguinal hernia surgery can be moderate to severe, interfering with return to normal activity. The study aimed to assess the efficacy of bilateral ultrasound-guided (USG) transversus abdominis plane (TAP) block for relieving acute pain after laparoscopic hernia repair as T10-L1 nerve endings are anesthetized with this block. METHODS Seventy-one American Society of Anesthesiologists I to II patients, aged 18 to 65 years, undergoing unilateral/bilateral laparoscopic hernia repair were randomized to port site infiltration (control, 36) and TAP block groups (35). All patients received general anesthesia (fentanyl 2 μg/kg intravenously at induction, 0.5 μg/kg on 20% increase in heart rate or mean blood pressure) and paracetamol 6 hourly. Postintubation, TAP group received bilateral USG TAP block (15-20 mL 0.5% ropivacaine, maximum 3 mg/kg) with 18-G Tuohy needle. Control group had 20 to 30 mL 0.5% ropivacaine infiltrated preincision, at port sites from skin to peritoneum. Postoperative patient-controlled analgesia fentanyl was provided for 6 hours; pain was assessed using 0- to 100-mm visual analog scale (VAS) at 0, 1, 2, 4, 6, and 24 hours and telephonically at 1 week and 3 months. RESULTS Demographic profile of the 2 groups was comparable. Significantly more number of patients required intraoperative fentanyl in the control group (24/36) than in the TAP group (13/35); VAS at rest was lower in TAP than control patients in postanesthesia care unit at 0, 2, 6, and 24 hours (median VAS TAP group: 0, 0, 0, and 0; control: 10, 20, 10, and 10; P= .002, P= .001, P= .001, and P= .006, respectively); P< .01 was considered statistically significant. TAP group had significantly lower VAS on deep breathing at 6 hours and on knee bending and walking at 24 hours and lesser patient-controlled analgesia fentanyl requirement. No significant difference in pain scores was observed at 1 week and 3 months. CONCLUSION TAP block reduced postoperative pain up to 24 hours after laparoscopic hernia repair.

Analgesic efficacy of single-dose parecoxib for corneal suturing in children.

EDITOR: Corneal injuries in children are still common in developing countries. Suturing of corneal perforations is undertaken under general anaesthesia utilizing opioids. The efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) has not been evaluated for this procedure. We conducted this randomized, double-blind study to assess whether a single dose of parecoxib could be a satisfactory alternative to fentanyl, and whether topical proparacaine, a local anaesthetic, would enhance the quality of perioperative analgesia in children receiving parecoxib. Following departmental approval and informed, written parental consent, 110 (American Society of Anesthesiologists Grade I/II) children aged 7–14 yr, scheduled for repair of corneal perforation were enrolled in the study. Intravenous (i.v.) access was obtained after topical eutectic mixture of anaesthetics cream application. All children were taught to express postoperative pain in terms of a verbal response score (VRS) ranging from 0 denoting no pain to 3 denoting unbearable pain. Children were randomly allocated to one of three groups: Group F (i.v. fentanyl 2 mg kg), Group P (i.v. parecoxib 20 mg up to 35 kg weight and 40 mg if weight .35 kg) and Group PL (parecoxib as in Group P and five drops of 0.25% proparacaine topically). After applying routine monitoring, fentanyl or parecoxib was injected over 2 min. Anaesthesia was induced with propofol and a laryngeal mask (LM) was inserted. Anaesthesia was maintained with rocuronium and isoflurane in 40% oxygen–nitrous oxide with mechanical ventilation. Intraoperative monitoring included heart rate, mean arterial pressure, need for rescue analgesic (0.5 mg kg fentanyl) and number of episodes of oculocardiac reflex. Neuromuscular block was reversed and the LM removed at the end of surgery after a dressing had been applied. In the postanaesthesia care unit (PACU), a nurse assessed the pain status on a 3-point scale ranging from 0 (quiet/sleeping) to 2 (crying/obvious pain/distress). The VRS was used on awakening. For a nurse-assessed score of 2 or VRS > 2, fentanyl 1 mg kg was administered. All children were sent to their ward after 1 h in the PACU. Pain was re-assessed at 2, 6 and 12 h. When a child complained of pain in the ward, oral ibuprofen syrup 10 mg kg was administered by the ward nurse and one of the investigators was notified. The final pain score and parental satisfaction of the child’s comfort was evaluated at 24 h. A total of 90 children were finally analysed (30 in each group). The patient characteristics data were comparable. Intraoperative rescue was required by four children in Group F and seven children in Group P compared with one child in Group PL (P , 0.001). Children in Group F had more episodes of the oculocardiac reflex (17) than in the P (1) and PL (3) groups (P , 0.001). On awakening 12 children in Group F required analgesia compared to one in Group P and none in Group PL (P , 0.001 for both). Twelve children in Group F required at least two doses of ibuprofen (up to 24 h) compared with four (single dose) in Group PL (P , 0.05) and six (single dose) in Group P (P , 0.05). Antiemetic treatment was required by 18 patients in Group F compared with three in Group PL and four in Group P (P , 0.001). At 24 h, eight children in Group F had a VRS score of 1; it was 0 in both P and PL groups. Parents of children in Groups P and PL were satisfied with their child’s comfort, whereas 14 parents in Group F were upset about postoperative nausea and vomiting. Although the role of cyclooxygenase-2 inhibitors in children is poorly defined, their use is common [1], primarily for arthritis [2]. Rofecoxib in adenotonsillectomy has been found to be superior to Correspondence to: Rajeshwari Subramaniam, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India. E-mail: rajeshwarisubramaniam@hotmail.com; Tel: 191 11 26193120, 191 9810079229; Fax: 191 11 26588500

The evaluation of efficacy and safety of paravertebral block for perioperative analgesia in patients undergoing laparoscopic cholecystectomy

Background: Paravertebral block is a popular regional anesthetic technique used for perioperative analgesia in multiple surgical procedures. There are very few randomized trials of its use in laparoscopic cholecystectomy in medical literature. This study was aimed at assessing its efficacy and opioid-sparing potential in this surgery. Methods: Fifty patients were included in this prospective randomized study and allocated to two groups: Group A (25 patients) receiving general anesthesia alone and Group B (25 patients) receiving nerve-stimulator–guided bilateral thoracic Paravertebral Block (PVB) at T6 level with 0.3 ml/kg of 0.25% bupivacaine prior to induction of general anesthesia. Intraoperative analgesia was supplemented with fentanyl (0.5 μg/kg) based on hemodynamic and clinical parameters. Postoperatively, patients in both the groups received Patient-Controlled Analgesia (PCA) morphine for the first 24 hours. The efficacy of PVB was assessed by comparing intraoperative fentanyl requirements, postoperative VAS scores at rest, and on coughing and PCA morphine consumption between the two groups. Results: Intraoperative supplemental fentanyl was significantly less in Group B compared to Group A (17.6 μg and 38.6 μg, respectively, P =0.001). PCA morphine requirement was significantly low in the PVB group at 2, 6, 12, and 24 hours postoperatively compared to that in Group A (4.4 mg vs 6.9 mg, 7.6 mg vs 14.2 mg, 11.6 mg vs 20.0 mg, 16.8 mg vs 27.2 mg, respectively; P <0.0001 at all intervals). Conclusion: Pre-induction PVB resulted in improved analgesia for 24 hours following laparoscopic cholecystectomy in this study, along with a significant reduction in perioperative opioid consumption and opioid-related side effects.

Comparison of topical lignocaine gel and fentanyl for perioperative analgesia in children undergoing cataract surgery.

Background:  Opioids continue to remain the primary analgesics in children undergoing ophthalmic surgery, and their use may be associated with adverse effects like vomiting and respiratory depression. Topical anesthesia avoids these adverse effects and also complications of regional blocks. We designed this study to verify whether topical anesthesia with lignocaine gel is a feasible alternative to intravenous (IV) fentanyl for pediatric cataract surgery.

Comparison of Absorbable Versus Nonabsorbable Tackers in Terms of Long-term Outcomes, Chronic Pain, and Quality of Life After Laparoscopic Incisional Hernia Repair: A Randomized Study.

Background: Laparoscopic incisional and ventral hernia repair (LIVHR) has been associated with a high incidence acute and chronic pain due to use of nonabsorbable tackers. Several absorbable tackers have been introduced to overcome these complications. This randomized study was done to compare 2 techniques of mesh fixation, that is, nonabsorbable versus absorbable tackers for LIVHR. Materials and Methods: Ninety patients admitted for LIVHR repair (defect size <15 cm) were randomized into 2 groups: nonabsorbable tacker fixation (NAT group, 45 patients) and absorbable tacker fixation (AT group, 45 patients). Intraoperative variables and postoperative outcomes were recorded and analyzed. Results: Patients in both the groups were comparable in terms of demographic profile and hernia characteristics. Mesh fixation time and operation time were also comparable. There was no significant difference in the incidence of immediate postoperative and chronic pain over a mean follow-up of 8.8 months. However, cost of the procedure was significantly higher in AT group (P<0.01) and NAT fixation was more cost effective as compared with AT. Postoperative quality of life outcomes and patient satisfaction scores were also comparable. Conclusions: NAT is a cost-effective method of mesh fixation in patients undergoing LIVHR with comparable early and late postoperative outcomes in terms of pain, quality of life, and patient satisfaction scores.