Ruchi Gupta

Correlation between Epidurographic Contrast Flow Patterns and Clinical Effectiveness in Chronic Lumbar Discogenic Radicular Pain Treated with Epidural Steroid Injections Via Different Approaches.

Background Epidural steroid injections are an accepted procedure for the conservative management of chronic backache caused by lumbar disc pathology. The purpose of this study was to evaluate the epidurographic findings for the midline, transforaminal and parasagittal approaches in lumbar epidural steroid injections, and correlating them with the clinical improvement. Methods Sixty chronic lower back pain patients with unilateral radiculitis from a herniated/degenerated disc were enrolled. After screening the patients according to the exclusion criteria and randomly allocating them to 3 groups of 20 patients, fluoroscopic contrast enhanced epidural steroids were injected via midline (group 1), transforaminal (group 2) and parasagittal interlaminar (group 3) approaches at the level of the pathology. The fluoroscopic patterns of the three groups were studied and correlated with the clinical improvement measured by the VAS over the next 3 months; any incidences of complications were recorded. Results The transforaminal group presented better results in terms of VAS reduction than the midline and parasagittal approach groups (P < 0.05). The epidurography showed a better ventral spread for both the transforaminal (P < 0.001) and the paramedian approaches (P < 0.05), as compared to the midline approach. The nerve root filling was greater in the transforaminal group (P < 0.001) than in the other two groups. The ventral spread of the contrast agent was associated with improvement in the VAS score and this difference was statistically significant in group 1 (P < 0.05), and highly significant in groups 2 and 3 (P < 0.001). In all the groups, any complications observed were transient and minor. Conclusions The midline and paramedian approaches are technically easier and statistically comparable, but clinically less efficacious than the transforaminal approach. The incidence of ventral spread and nerve root delineation show a definite correlation with clinical improvement. However, an longer follow-up period is advisable for a better evaluation of the actual outcom.

Unanticipated cardiac arrest under spinal anesthesia: An unavoidable mystery with review of current literature

Cardiac arrest during anesthesia and perioperative period is a matter of grave concern for any anesthesiologist. But such mishaps have been reported for one reason or the other in the literary sciences. We are reporting the occurrence of unanticipated delayed cardiac arrest following spinal anesthesia in two young and healthy patients. Fortunately, these patients were successfully resuscitated with timely and appropriate cardiopulmonary resuscitative measures. Occurrence of such cases needs timely reporting and exploring all the possible causes of these unusual and possibly avoidable events. The present case reports are an important addition to a series of recently published mishaps that occurred during spinal anesthesia in young and healthy patients.

Post-herpetic neuralgia: A review of current management strategies

Post herpetic neuralgia (PHN) is a chronic neuropathic pain in the region of the herpes zoster (HZ) rash, persisting after the cutaneous lesions have healed. Despite numerous treatment advances, many patients remain refractory to the current therapies and continue to have pain, physical and psychological distress. In this review, we will discuss the current strategies for prevention and management of this disease, as also the insight into the future probabilities.

Tracheal intubation through Igel conduit in a child with post-burn contracture

Sir, A 25 kg, 9 year old girl was scheduled for post-burn contracture (PBC) neck release and superficial skin grafting following burns. Contracture scar was in the anterior midline of the neck. Neck extension was limited, and interincisor gap was ~ 3.5 cm. All relevant investigations were within normal limits. Standard monitors were attached and intravenous (IV) access was secured on the dorsum of the left hand. Patient was administered glycopyrrolate 0.2 mg, ranitidine 25 mg, metoclopromide 8 mg and fentanyl 50 mcg (IV). Anesthesia was induced with Sevoflurane 2 8% in 100% oxygen (O2) using a size 2 facemask. After adequate jaw relaxation, Igel size 2.5 was inserted, and placement was confirmed by a square shaped capnography wave. Spontaneous ventilation was maintained. An assembly of two uncuffed endotracheal tubes (ETT) of 5.5 mm ID (up to 6 mm ID size, ETT can pass through Igel size 2.5[1]) with connectors removed was created [Figure 1], such that the proximal end of lower tube firmly fitted into the distal end of the upper tube making them a single unit to increase the length of ETT for Igel removal after endotracheal intubation. This assembly was mounted over flexible fiberscope (ED 3.7 mm). Flexible fiberscope with 5.5 mm ID (ETT) over it was kept ready. The surgeon was asked to standby for scar release in an emergency. Depth of anesthesia was maintained with sevoflurane 4-5% in 100% O2.

Postspinal hypotension in elderly patients undergoing orthopedic surgery, prophylactic ephedrine versus polygeline 3.5.

Context: Perioperative fluid management in elderly poses considerable challenge to the anesthesiologist. The conventional crystalloid loading may not be a preferred regime in this subgroup of patients since an exaggerated hemodynamic response is expected due to blunted sympathetic response and compromised cardiorespiratory system. Aims: This study was designed in the elderly patient for comparing efficacy, side-effects and limitations of prophylactic ephedrine 30 mg (intramuscular [i.m.]) versus polygeline 3.5% 500 ml (intravenous [i.v.]) for the maintenance of blood pressure after subarachnoid block (SAB). Settings and Design: The sample size of 100 elderly (age > 50 years) patients undergoing orthopedic surgeries was administered SAB using bupivacaine 0.5% heavy. The primary outcome of this study was the attenuation of hypotension due to SAB using ephedrine or polygeline 3.5%. Materials and Methods: A total of 100 patients were randomly allocated to receive ephedrine 30 mg i.m. 10 min before the institution of SAB in Group I and preloading with 500 ml of polygeline 3.5% i.v. over 10 min prior to SAB in Group II. Patients in both groups were closely monitored for pulse rate, systolic blood pressure; any hypotension, requirement of rescue therapy and adverse effects. Statistical Analysis Used: Results were interpreted using Students t-test for parametric and Chi-square tests for nonparametric data. Results: The incidence of hypotension and requirement for rescue therapy was statistically less in Group I compared with Group II (P < 0.05). Heart rates were better maintained in Group I than Group II, with few hemodynamic adverse effects in both groups. Conclusions: Ephedrine 30 mg i.m. given as pretreatment before SAB in elderly patients was more effective for the prevention of post-SAB hypotension.

Impact of different approaches of epidural steroid injection on outcome of patients treated for low backache

Objectives: The objective of this study was to evaluate the clinical efficacy of epidural steroid injections through different approaches using pain relief and improvement in functional capacity as outcome measures. Materials and Methods: Sixty patients with low backache and unilateral radiculopathy were randomly assigned to three groups of twenty patients each, for undergoing lumbar epidural steroid injection (LESI) through midline, transforaminal, and paramedian approaches under fluoroscopic guidance. All the patients were assessed at 1 week, 1 month and 3 months postintervention using visual analog scale (VAS) score, Quebec disability score, and depression score. Results: The primary and secondary outcome measured in terms of improvement of VAS showed statistically significant reduction (P < 0.05) when compared to preprocedure baseline readings on both intragroup analysis (Groups I, II and III) at 1-week, 1-month, and 3-month follow-up. However, on intergroup comparison, the difference in improvement of VAS score noted was statistically insignificant with P value of 0.07 (Group I/II), 0.19 (Group II/III), 0.85 (Group I/III) at final 3rd month follow-up. In addition, intergroup comparison for secondary outcome showed statistically insignificant improvement (P value for Quebec score 0.73 [Group I/II], 0.34 [Group II/III], 0.79 [Group I/III] and depression score 0.78 [Group I/II], 0.67 [Group II/III], 0.98 [Group I/III]) at final 3rd month follow-up. Conclusions: All three LESI approaches proved highly effective individually in terms of short-term pain relief, improvement in the quality of life, and depression; however, none proved to be better than the other.

A study to compare the quality of surgical field using total intravenous anesthesia (with propofol) versus inhalational anesthesia (with isoflurane) for functional endoscopic sinus surgeries

Background and Objectives: Functional endoscopic sinus surgery (FESS) being a delicate technique, intraoperative bleeding is one of the major challenges. Even a little bleeding can adversely affect the surgeons ability to visualize the region to be operated. General anesthesia is preferred over topical anesthesia in FESS. This study was conducted to compare the surgical field using total intravenous anesthesia (TIVA) with propofol and inhalational anesthesia with isoflurane for FESS. Secondary outcomes such as intraoperative blood loss and the incidence of perioperative complications were also recorded. Subjects and Methods: A total of sixty patients in the age group of 16–60 years with physical status American Society of Anesthesiologists Classes I and II, undergoing FESS were randomly divided into two groups of thirty each after taking informed consent and approval from the Hospital Ethics Committee. Thirty patients in Group I: received isoflurane-based inhalational anesthesia and other Thirty patients in Group II: were administered TIVA with propofol. Various parameters were recorded and statistically analyzed. Results: There was improved quality of surgical field at the end of surgery in the Group II as compared to Group I. Total blood loss during surgery and incidence of intraoperative complications were less in Group II as compared to Group I. Conclusion: This study concludes that in FESS, using TIVA with propofol decreases blood loss and the incidence of complications during surgery in addition to providing good quality of surgical field.

Dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block: A novel anesthetic approach

Aims and Objectives: Supplementation of dexmedetomidine produces a dose-dependent sedation, anxiolysis and analgesia without respiratory depression. This study was conducted to evaluate the possible effect of dexmedetomidine as an adjuvant to levobupivacaine for supraclavicular brachial plexus block in upper limb surgery. Settings and Design: Tertiary care institute, Department of Anaesthesiology and Intensive Care, a placebo-controlled study. Materials and Methods: After obtaining Ethical Committee approval, a randomized, double-blind, placebo-controlled study was conducted on sixty American Society of Anesthesiologists physical status I and II patients in the age group of 18–60 years, divided randomly into two groups, Group I received 30 ml of 0.5% levobupivacaine with 1 ml of isotonic sodium chloride solution and Group II received 30 ml of 0.5% levobupivacaine and 1 ml (100 mcg) of dexmedetomidine for supraclavicular brachial plexus block. The onset and duration of sensory and motor blockade, duration of analgesia (DOA) and any adverse effects were noted. At the end of the study, data were compiled and analyzed using appropriate statistical tests. The value of P< 0.05 was considered significant. Results: Demographic profile was comparable in both the groups. The time to onset of sensory and motor block was 10.54 ± 2.333 min and 12.21 ± 2.529 min in Group I while it was 3.24 ± 0.951 min and 2.83 ± 1.197 min in Group II, respectively. The duration of sensory and motor block was 7.79 ± 2.007 h and 9.18 ± 1.701 h in Group I, and it was 16.31 ± 2.606 h and 17.52 ± 2.098 h in Group II, respectively. The DOA was 678.68 ± 20.492 min in Group I and 1273.79 ± 83.139 min in Group II. On statistical comparison, these values were highly significant (P < 0.001). Side effects such as nausea, vomiting, hypoxemia, pruritis, or urinary retention were not observed in either of the groups. Conclusion: Dexmedetomidine shortens the onset time for sensory and motor block significantly and prolongs DOA as well when used with levobupivacaine for supraclavicular brachial plexus block, without increasing the incidence of any adverse effects.

Sinus arrest with intrathecal dexmedetomidine

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Streptococcus agalactiae causing pyometra in an elderly female with cervical cancer

Streptococcus agalactiae is an important cause of invasive infections in neonates and is emerging as an important pathogen in elderly females. S. agalactiae is a commensal organism of the female genital tract; however, isolation from the uterine cavity suggests ascending infection of this organism caused by occlusion of the uterine cavity. We report a case of S. agalactiae causing pyometra in an elderly female with cervical cancer.