Shelly Rana

Garlic in health and disease

The present article reviews the historical and popular uses of garlic, its antioxidant, haematological, antimicrobial, hepatoprotective and antineoplastic properties and its potential toxicity (from sulfoxide). Garlic has been suggested to affect several cardiovascular risk factors. It has also been shown that garlic and its organic allyl sulfur components are effective inhibitors of the cancer process. Since garlic and its constituents can suppress carcinogen formation, bioactivation and tumour proliferation, it is imperative that biomarkers be established to identify which individuals might benefit most. Garlic powder, aged garlic and garlic oil have demonstrated antiplatelet and anticoagulant effects by interfering with cyclo-oxygenase-mediated thromboxane synthesis. Garlic has also been found to have synergistic effects against Helicobacter pylori with a proton pump inhibitor. The active compound allicin may affect atherosclerosis not only by acting as an antioxidant, but also by other mechanisms, such as lipoprotein modification and inhibition of LDL uptake and degradation by macrophages. Freshly prepared garlic homogenate protects against isoniazid+rifampicin-induced liver injury in experimental animal models. Several mechanisms are likely to account for this protection.

To compare CSF adenosine deaminase levels and CSF-PCR for tuberculous meningitis

This study was planned to compare the adenosine deaminase (ADA) levels and polymerase chain reaction (PCR) in cerebrospinal fluid (CSF) as a rapid method to diagnose tuberculosis meningitis (TBM). Fifty-four adult patients with suspected TBM and 37 controls were included in this study. The median ADA level was 21U/L of most likely TBM, 14U/L of unconfirmed TBM and 5U/L of controls. PCR for Mycobacterium tuberculosis was positive in 12 out of 27 most likely TBM cases, 5 out of 27 unconfirmed TBM cases and 3 out of 37 controls. Using a cut off level of >10U/L, CSF-ADA had a sensitivity of 92.5% and specificity of 97% for the diagnosis of TBM. PCR for M. tuberculosis had a sensitivity of 44.5% and specificity 92% in the most likely TBM cases. This study shows that CSF-ADA is a more sensitive indicator than PCR for the diagnosis of M. tuberculosis.

Magnesium sulphate as an adjuvant to bupivacaine in ultrasound-guided transversus abdominis plane block in patients scheduled for total abdominal hysterectomy under subarachnoid block

Background and Aims: Transversus abdominis plane (TAP) block has proven to be an effective component of multimodal analgesic regimens for a variety of abdominal procedures. Magnesium sulphate (MgSO4) N-methyl-D-aspartate receptor antagonist has the potential to be an ideal adjuvant in TAP block. We studied the efficacy of MgSO4as an adjuvant to bupivacaine in TAP block in patients scheduled for total abdominal hysterectomy (TAH) under subarachnoid block (SAB). Methods: Sixty-five women belonging to American Society of Anesthesiologists physical status 1 or 2, aged between 35 and 70 years, scheduled for TAH under SAB were recruited. Patients in Group B (n = 32) received 18 mL 0.25% bupivacaine (45 mg) with 2 mL normal saline (NS), whereas those in Group BM (n = 33) received 18 mL 0.25% bupivacaine (45 mg) with 1.5 mL (150 mg) MgSO4and 0.5 mL NS in the ultrasound (USG)-guided TAP block performed on each side after the completion of the surgery under SAB. They were evaluated for pain at 0, 2, 4, 6, 12 and 24 h, time to first rescue analgesic and duration of postoperative analgesia were noted. Results: The post-operative visual analogue scale (VAS) scores were lower in Group BM at 4, 6 and 12 h (P < 0.05). Mean duration of analgesia was significantly prolonged in Group BM with lesser requirement of rescue analgesic (P < 0.05) up to 12 h. Conclusion: MgSO4 (150 mg) as an adjuvant to bupivacaine in USG-guided TAP block reduces post-operative pain scores, prolongs the duration of analgesia and decreases demands for rescue analgesics.

Comparative study of systemically and perineurally administered tramadol as an adjunct for supraclavicular brachial plexus block

Background and Aims: The study was designed to compare the effects of tramadol administered as an adjunct to bupivacaine in supraclavicular block to that of systemic administration, on postoperative analgesia and rescue analgesic requirement following upper limb surgeries. Material and Methods: A prospective, randomized, controlled, double-blind study was undertaken in patients scheduled for upper limb surgeries under supraclavicular block. All the three group patients received either of the following drugs mixtures: Group A — bupivacaine 0.5%-18 ml + normal saline-7 ml for block and normal saline-10 ml intravenously. Group B — bupivacaine 0.5%-18 ml + normal saline-7 ml mixture for block and tramadol (100 mg) diluted to 10 ml — intravenously. Group C — bupivacaine 0.5%-18 ml + tramadol (100 mg) + normal saline-5 ml mixture and normal saline 10 ml intravenously. The patients were observed for sensory, motor onset along with the duration of sensory and motor block. Patients were monitored for sedation and hemodynamic parameters during intra-operative and postoperative period. Pain-free period and demand for rescue analgesia was noted in all the patients. Results: The study demonstrates that the mixture of tramadol and bupivacaine injected perineurally for supraclavicular brachial plexus block hastens the onset of sensory block, motor block and provides a longer duration of motor blockade and demand for rescue analgesia as compared to other two groups. Conclusions: In conclusion, the addition of tramadol to bupivacaine mixtures as an adjunct for supraclavicular brachial plexus block provide better postoperative analgesia for orthopedic upper extremity surgery in comparison to control or systemic tramadol group without any side effects.

Ultrasound-guided femoro-sciatic nerve block for post-operative analgesia after below knee orthopaedic surgeries under subarachnoid block: Comparison between clonidine and dexmedetomidine as adjuvants to levobupivacaine

Background and Aims: The advent of ultrasonographic-guided techniques has led to increased interest in femoro-sciatic nerve block (FSNB) for lower limb surgeries. α2-agonists have been used recently as adjuvants to local anaesthetics in nerve blocks. We aimed to compare equal doses of clonidine or dexmedetomidine as an adjuvant to levobupivacaine in FSNB for post-operative analgesia. Methods: Ninety patients scheduled to undergo below knee orthopaedic surgeries under subarachnoid block were divided into three groups: Group LL (n = 30) patients received 38 mL of 0.125% levobupivacaine with 2 mL normal saline, Group LD (n = 30) patients received 38 mL of 0.125% levobupivacaine with 0.5 μg/kg dexmedetomidine and Group LC (n = 30) received 38 mL of 0.125% levobupivacaine with 0.5 μg/kg clonidine in saline to make total drug volume of 40 mL. The primary and secondary outcome variables were duration of analgesia and rescue analgesic requirement, verbal rating score respectively. Continuous variables were analysed with analysis of variance or the Kruskal–Wallis test on the basis of data distribution. Categorical variables were analysed with the contingency table analysis and the Fishers exact test. Results: Duration of analgesia was prolonged with dexmedetomidine (10.17 ± 2.40 h) and clonidine (7.31 ± 1.76 h) as compared to control (4.16 ± 1.04 h, P= 0.00). Significantly lower pain scores were observed in dexmedetomidine group as compared to clonidine up to 8 h post-operatively. Conclusion: Equal doses of clonidine or dexmedetomidine added to levobupivacaine prolonged the duration of analgesia, decreased requirement of rescue analgesia. Dexmedetomidine delays the requirement of rescue analgesics with better pain scores as compared to clonidine.

Single-stage management of large pulmonary and hepatic hydatid cysts in pediatric age group: Report of two cases

Two patients presented to us with very similar clinical and radiological presentation of huge hydatid cysts in the lung and liver. The first patient was an 11-year-old female child and the second one was a 9-year-old male child. The clinical features in both were breathlessness on exertion, pain abdomen, and abdominal distension. Chest Roentgenogram along with computed tomogram of the chest and abdomen revealed presence of thin-walled homogenous large cysts, one in the right lung and two in the liver, in both the cases. Although the liver cysts were of larger size and occupying most of the right lobe of the liver and part of the left lobe, liver function tests were normal. All three cysts were enucleated in the same sitting by a combined thoracic and abdominal approach (thoracotomy followed by laparotomy). After enucleation of the cyst, capitonnage of the cavity in the lung was done and the liver cavities were filled with omentum to prevent collection of fluid and abscess formation. Both patients recovered well, although the second patient required abdominal drain for a long period of 1 month for bile leakage which decreased gradually and eventually stopped.

Efficacy of magnesium sulphate and/or fentanyl as adjuvants to intrathecal low-dose bupivacaine in parturients undergoing elective caesarean section

Background and Aim: Recent developments in the field of intrathecal adjuvants have led to accelerated functional recovery with adequate postoperative analgesia following caesarean section. Encouraging results have been obtained with the use of intrathecal magnesium with or without fentanyl in parturients. This study was conceived to evaluate the effects of adding magnesium sulphate and/or fentanyl to low-dose intrathecal bupivacaine in parturients undergoing caesarean section under subarachnoid block (SAB). Materials and Methods: Ninety, American Society of Anesthesiologists I or II, parturients for the elective caesarean section were enrolled in this prospective randomized, double-blind study. The parturients were randomly assigned to three groups. In Group M, parturients received 8.5 mg (1.7 mL) hyperbaric bupivacaine 0.5% with 50 mg (0.1 mL) magnesium sulphate and 0.4 mL normal saline. Group F received 8.5 mg hyperbaric bupivacaine 0.5% with 20 μg (0.4 mL) fentanyl and 0.1 mL of normal saline and Group MF parturients received 8.5 mg hyperbaric bupivacaine 0.5% with 20 μg fentanyl added to 50 mg magnesium sulphate. Results: Parturients in the group MF were pain free for longest period (273.70 ± 49.30 min) as compared to group M (252.67 ± 40.76 min) and group F (239.80 ± 38.45 mins) [gp MF vs F and, gp M vs F (P = 0.00)]. The total doses of rescue analgesics were least in group MF (2.43 ± 0.56) and maximum in group F (3.30 ± 0.63), with comparable neonatal outcomes in three groups. Conclusion: Our data supports synergistic action of intrathecal magnesium sulphate to fentanyl, and it is concluded that on addition of intrathecal magnesium sulphate and fentanyl to low-dose bupivacaine as adjuvant in subarachnoid block, results in prolonged duration of postoperative analgesia with lesser pain scores and lesser dose of rescue analgesia with better haemodynamic stability.

A dose-finding randomised controlled trial of magnesium sulphate as an adjuvant in ultrasound-guided supraclavicular brachial plexus block

Background and Aim: Magnesium sulphate (MgSO4) has been used as an adjuvant in brachial plexus block with encouraging results; however, there is no consensus regarding its optimal dose. Thereby, we compared the efficacy of two doses of MgSO4 as an adjuvant in ultrasound (USG) guided supraclavicular brachial plexus block. Methods: Ninety patients, aged 20–60 years, belonging to American Society of Anesthesiologists physical status 1 or 2, were given USG-guided supraclavicular block. Group B (n = 30) received 20 ml of 0.5%bupivacaine + 5 ml normal saline (NS), Group BM0.5(n = 30) received 20 ml of 0.5%bupivacaine + 3.75 ml NS and 125 mg MgSO4 (1.25 ml) and Group BM1(n = 30) received 20 ml of 0.5%bupivacaine + 2.5 ml NS and 250 mg MgSO4 (2.5 ml). The primary outcome of study was the duration of post-operative analgesia. The normally distributed data were analysed using analysis of variance and categorical data analysed using Chi-square test. Results: Duration of post-operative analgesia was prolonged in Groups BM1 and BM0.5 (665.13 ± 97.874, 475.10 ± 53.294) min respectively as compared to Group B (272.03 ± 40.404 min: P = 0.00). The onset times of sensory and motor block were shorter in Group BM1 (5.17 ± 2.2 min)as compared to Groups BM0.5 and B (8.9 ± 2.3 and 17.7 ± 5.1 min: P = 0.00) respectively. Sensory and motor block durations were prolonged in Group BM1 as compared to BM0.5 and B (P = 0.00). Conclusions: MgSO4 as adjuvant in brachial plexus block increases the duration of post-operative analgesia. MgSO4 in the dose of 250mg has greater efficacy as compared to 125 mg.

Midazolam as an adjunct to lignocaine at two different doses in ultrasound-guided supraclavicular brachial plexus block: a randomized controlled trial

Background and aims The present study was carried out to investigate the efficacy of midazolam at two different doses as an adjunct to lignocaine with adrenaline in ultrasound-guided supraclavicular brachial plexus block. Materials and methods In this prospective controlled study, 95 consenting patients scheduled for forearm fracture surgeries were randomized into three groups. Five patients were excluded from the study for not meeting the inclusion criteria. Group L (n=30) received 20 ml of 1.5% lignocaine with adrenaline (1 : 200 000)+5 ml of normal saline (total volume=25 ml). Group M30 (n=30) received 20 ml of 1.5% lignocaine with adrenaline (1 : 200 000)+30 μg/kg midazolam+normal saline (total volume =25 ml). Group M50 (n=30) received 20 ml of 1.5% lignocaine with adrenaline (1 : 200 000)+50 μg/kg midazolam+normal saline (total volume =25 ml). Results The onset of sensory and motor block was found to be earliest in group M50, followed by group M30 and group L, and the difference was statistically significant (P<0.05). The mean duration of motor block and sensory block was longest in group M50 followed by groupM30 and shortest in group L, which was also statistically significant (P<0.05). The mean duration of analgesia was longest in group M50 (254.53±34.77 min) followed by group M30 (211.03±52.69 min) and shortest in group L (181.47±20.63 min). The differences were statistically significant (P<0.05). Group L received the highest doses of rescue analgesics (2.80±0.407 doses) followed by group M30 (1.97±0.615 doses) and group M50 (1.47±0.819 doses). The difference was statistically significant (P<0.05). Conclusion Midazolam increases the duration of sensory and motor blockade and delays need for rescue analgesic. In addition, midazolam at a dose of 50 μg/kg had superior therapeutic profile compared with 30 μg/kg, and hence may be the recommended dose.

Magnesium sulfate at two different doses as an adjuvant to bupivacaine in infraumblical (below knee) orthopedic surgeries under spinal anesthesia

Background The use of magnesium sulfate as an adjuvant in neuraxial block has gained popularity, with the aim of improving and enhancing the quality and duration of anesthesia, delaying the onset of postoperative pain, and thus reducing the demand for postoperative rescue analgesics. However, until today, there has been no consensus as regards the ideal dose of magnesium sulfate as an adjuvant in the subarachnoid block. The present study was designed to examine whether the addition of intrathecal magnesium sulfate (50 and 100 mg) would enhance the analgesic efficacy of intrathecal bupivacaine. We hypothesized that the additive effect of magnesium sulfate as an adjuvant to bupivacaine in subarachnoid block is dose dependent. Materials and methods This study was carried out on 90 American Society of Anesthesiology I and II patients of both sexes in the age group of 20–60 years scheduled for below knee surgeries under subarachnoid block. Group 1 (n = 30) patients received intrathecal 0.5% heavy bupivacaine (2.8 ml) +0.2 ml normal saline; group 2 (n = 30) received intrathecal 0.5% heavy bupivacaine (2.8 ml) +50 mg (0.1 ml) magnesium sulfate +0.1 ml normal saline; and group 3 (n = 30) received intrathecal 0.5% heavy bupivacaine (2.8 ml)+100 mg (0.2 ml) magnesium sulfate. The primary outcome measure was the duration of postoperative analgesia, and secondary outcomes included the number of supplemental analgesic requirements, block characteristics, and hemodynamic stability. Results The onset of sensory and motor block was delayed in the magnesium group (100 mg>50 mg). There was a significant prolongation of postoperative analgesia in the magnesium group in a dose-dependent manner, and total dose of rescue analgesic requirement was found to be significantly delayed in the 100 mg group. Patients in all groups remained hemodynamically stable without any adverse effects. Conclusion Magnesium sulfate (100 mg) as an adjuvant to bupivacaine in subarachnoid block prolongs the duration of analgesia and decreases the demand for rescue analgesics compared with the control and the magnesium sulfate 50 mg group.