Sujeet Gautam

Transdermal diclofenac patchvs eutectic mixture of local anesthetics for venous cannulation pain

PurposeTo compare the efficacy and side effects of transdermal diclofenac patch with eutectic mixture of local anesthetic (EMLA) cream in attenuating venous cannulation pain.MethodsAdult ASA I or II patients undergoing elective surgery were randomly divided into three groups of 150 each. Group 1 (Control) patients received a placebo patch; Group 2 (EMLA) patients received EMLA cream; Group 3 (Diclofenac) patients received a transdermal diclofenac patch. The patches were applied at the proposed venous cannulation site 60 min prior to cannulation and pain resulting from an 18G cannula was assessed on an ten-point visual analogue scale (VAS). The cannulation site was observed for blanching, erythema, induration and edema for up to 24 hr.ResultsThe incidence of venous cannulation pain was 100% in the control group, as compared to 37% and 48% of patients who experienced pain in the EMLA (P = 0.001) and diclofenac (P = 0.001) groups, respectively. The severity of venous cannulation pain [median (VAS) with interquartile ranges] was also higher in the control group: 6 (3) as compared to VAS sores of 0 (1) and 0 (2) in the EMLA (P = 0.001) and diclofenac (P = 0.001) groups. Blanching occurred with greater frequency in the EMLA group compared with the diclofenac (P = 0.001 at six hours) and placebo groups (P = 0.001 at six hours). Erythema, induration and edema were reduced in the diclofenac group compared with the EMLA (P = 0.001 for all comparisons) and placebo groups (P = 0.04 for edema at six hours andP = 0.001 for other comparisons).ConclusionTransdermal diclofenac patch and EMLA are equally effective in reducing venous cannulation pain, but signs of erythema, induration and edema are less frequently observed with the transdermal diclofenac patch.RésuméObjectifComparer l’efficacité et les effets secondaires du diclofenac transdermique au mélange eutectique d’anesthésiants locaux en crème (EMLA®) pour atténuer les douleurs associées au cathétérisme veineux.MéthodeDes patients adultes ASA I et II devant subir une chirurgie élective ont été randomisés en trois groupes de 150. Un timbre placebo a été donné au groupe 1 (témoin); le groupe 2 (EMLA®) a reçu la crème EMLA®; le groupe 3 a reçu un timbre de diclofenac transdermique. Les timbres ont été appliqués au site prévu de canulation veineuse 60 min avant le cathétérisme, et la douleur provoquée par une canule de 18G a été évaluée sur une échelle visuelle analogue de onze points (EVA). L’apparition de blanchiment, d’érythème, d’induration ou d’œdème de la peau au site de canulation a été surveillée jusqu’à 24 h.RésultatsL’incidence de douleur associée à la canulation veineuse fut de 100 % dans le groupe témoin, comparée à 37 % et 48 % dans les groupes EMLA® (P = 0,001) et diclofenac (P = 0,001) respectivement. La sévérité de la douleur associée à la canulation veineuse [(EVA) médian avec variations de quartile] fut également plus élevée dans le groupe témoin: 6 (3) sur l’échelle EVA comparé à 0 (1) et 0 (2) dans les groupes EMLA® (P = 0,001) et diclofenac (P = 0,001). L’apparition de blanchiment cutané fut plus fréquente dans le groupe EMLA® comparé aux groupes diclofenac (P = 0,001 à six heures) et placebo (P = 0,001 à six heures). Les érythèmes, indurations et oedèmes furent diminués dans le groupe diclofenac comparé aux groupes EMLA® (P = 0,001 pour toutes les comparaisons) et placebo (P = 0,04 pour l’œdème à six heures et P = 0,001 pour les autres comparaisons).ConclusionLe diclofenac transdermique et la crème EMLA® sont tous deux efficaces pour réduire la douleur associée à la ponction veineuse, mais les signes d’érythème, d’induration et d’œdème cutané sont moins fréquents avec le diclofenac transdermique.

Evaluation of the Efficacy of Methylprednisolone, Etoricoxib and a Combination of the Two Substances to Attenuate Postoperative Pain and PONV in Patients Undergoing Laparoscopic Cholecystectomy: A Prospective, Randomized, Placebo-controlled Trial

Background Establishment of laparoscopic cholecystectomy as an outpatient procedure has accentuated the clinical importance of reducing early postoperative pain, as well as postoperative nausea and vomiting (PONV). We therefore planned to evaluate the role of a multimodal approach in attenuating these problems. Methods One hundred and twenty adult patients of ASA physical status I and II and undergoing elective laparoscopic cholecystectomy were included in this prospective, randomized, placebo-controlled study. Patients were divided into four groups of 30 each to receive methylprednisolone 125 mg intravenously or etoricoxib 120 mg orally or a combination of methylprednisolone 125 mg intravenously and etoricoxib 120 mg orally or a placebo 1 hr prior to surgery. Patients were observed for postoperative pain, fentanyl consumption, PONV, fatigue and sedation, and respiratory depression. Results were analyzed by the ANOVA, a Chi square test, the Mann Whitney U test and by Fishers exact test. P values of less than 0.05 were considered to be significant. Results Postoperative pain and fentanyl consumption were significantly reduced by methylprednisolone, etoricoxib and their combination when compared with placebo (P<0.05). The methylprednisolone + etoricoxib combination caused a significant reduction in postoperative pain and fentanyl consumption as compared to methylprednisolone or etoricoxib alone (P<0.05); however, there was no significant difference between the methylprednisolone and etoricoxib groups (P>0.05). The methylprednisolone and methylprednisolone + etoricoxib combination significantly reduced the incidence and severity of PONV and fatigue as well as the total number of patients requiring an antiemetic treatment compared to the placebo and etoricoxib (P<0.05). Conclusions A preoperative single-dose administration of a combination of methylprednisolone and etoricoxib reduces postoperative pain along with fentanyl consumption, PONV, antiemetic requirements and fatigue more effectively than methylprednisolone or etoricoxib alone or a placebo.

Comparative evaluation of esmolol and dexmedetomidine for attenuation of sympathomimetic response to laryngoscopy and intubation in neurosurgical patients.

Background and Aims: The present study compared the efficacy of esmolol and dexmedetomidine for attenuation of the sympathomimetic response to laryngoscopy and intubation in elective neurosurgical patients. Material and Methods: A total of 90 patients aged 20-60 years, American Society of Anesthesiologists physical status I or II, either sex, scheduled for elective neurosurgical procedures were included in this study. Patients were randomly allocated to three equal groups of 30 each comprising of Control group (group C) 20 ml 0.9% saline intravenous (IV), group dexmedetomidine (group D) 1 μg/kg diluted with 0.9% saline to 20 ml IV and group esmolol (group E) 1.5 mg/kg diluted with 0.9% saline to 20 ml IV. All the drugs were infused over a period of 10 min and after 2 min induction of anesthesia done. Heart rate (HR), systolic blood pressure, diastolic blood pressure, and mean arterial pressure were recorded baseline, after study drug administration, after induction and 1, 2, 3, 5, 10, and 15 min after orotracheal intubation. Results: In group D, there was no statistically significant increase in HR and blood pressure after intubation at any time intervals, whereas in group E, there was a statistical significant increase in blood pressure after intubation at 1, 2, and 3 min only and HR up to 5 min. Conclusion: Dexmedetomidine 1 μg/kg is more effective than esmolol for attenuating the hemodynamic response to laryngoscopy and intubation in elective neurosurgical patients.

Evaluation of efficacy of Valsalva maneuver for attenuating propofol injection pain: a prospective, randomized, single blind, placebo controlled study

Background Pain on injection is a limitation with propofol use. The effect of the Valsalva maneuver on pain during propofol injection has not been studied. This maneuver reduces pain through the sinoaortic baroreceptor reflex arc and by distraction. We aimed to assess the efficacy of the Valsalva maneuver in reducing pain during propofol injection. Methods Eighty American Society of Anesthesiologists class I adult patients undergoing general anesthesia were enrolled and divided into two groups of 40 each. Group I (Valsalva) patients blew into a sphygmomanometer tube raising the mercury column up to 30 mmHg for 20 seconds, while Group II (Control) patients did not. Anesthesia was induced with 1% propofol immediately afterwards. Pain was assessed on a 10-point visual analog scale (VAS), where 0 represented no pain, and 10, the worst imaginable pain, and a 4-point withdrawal response score, where 0 represented no pain, and 3, the worst imaginable pain. Scores were presented as median (interquartile range). Results We analyzed the data of 70 patients. The incidence of pain was significantly lower in the Valsalva than in the control group (53% vs 78%, P = 0.029). The withdrawal response score was significantly lower in the Valsalva group (1.00 [0.00-1.00] vs 2.00 [2.00-3.00], P < 0.001). The VAS score was significantly lower in the Valsalva group (1.00 [0.00-4.00] vs 7.00 [6.25-8.00], P < 0.001). Conclusions A prior Valsalva maneuver is effective in attenuating injection pain due to propofol; it is advantageous in being a non-pharmacological, safe, easy, and time-effective technique.

Abdominal wall myofascial pain: still an unrecognized clinical entity

Received April 25, 2017. Revised June 8, 2017. Accepted June 9, 2017. Correspondence to: Sujeet Gautam Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India Tel: +91-522-2495526, Fax: +91-522-2668017, E-mail: docsksg@gmail.com This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c The Korean Pain Society, 2017 LETTERS TO EDITOR

Chronic pain in a patient with Ehlers-Danlos syndrome (hypermobility type): The role of myofascial trigger point injections

Chronic widespread musculoskeletal pain is a cardinal symptom in hypermobility type of Ehler Danlos Syndrome (EDS type III). The management of pain in EDS, however, has not been studied in depth. A 30 year old female, known case of EDS, presented to the pain clinic with complaints of severe upper back pain for 6 months. Physical examination of the back revealed two myofascial trigger points over the left rhomboids and the left erector spinae. Local anaesthetic trigger point injections were given at these points, followed by stretching exercises under analgesic cover for the first week. After 1 week the patient reported 60-80% pain relief. This case highlights that we must keep a high index of suspicion for the more treatable causes of pain like myofascial pain syndrome in patients suffering from EDS, and should address it promptly and appropriately in order to maximise patient comfort.

Comparative evaluation of continuous thoracic paravertebral block and thoracic epidural analgesia techniques for post-operative pain relief in patients undergoing open nephrectomy: A prospective, randomized, single-blind study

Background: Open surgical procedures are associated with substantial postoperative pain; an alternative method providing adequate pain relief with minimal side effects is very much required. Aim: The aim of this study was a comparative evaluation of the efficacy of continuous thoracic paravertebral block (PVB) and thoracic epidural analgesia (EA) for postoperative pain relief in patients undergoing open nephrectomy. Settings and Design: Prospective, randomized, and single-blind study. Materials and Methods: Sixty adult patients undergoing open nephrectomy under general anesthesia were randomized to receive a continuous thoracic epidural infusion (Group E) or continuous thoracic paravertebral infusion (Group P) with bupivacaine 0.1% with 1 μg/ml fentanyl at 7 ml/h; both infusions were started after induction of anesthesia. The primary outcome measures were postoperative pain during rest (static pain), deep inspiration, coughing, and movement (getting up from supine to sitting position); the secondary outcome measures were postoperative nausea and vomiting, requirement of rescue antiemetic, hypotension, sedation, pruritus, motor block, and respiratory depression. These were assessed till the morning of the third postoperative day. Statistical Analysis: Results were analyzed by the one-way ANOVA, Chi-square test, and Mann–Whitney U-test. P< 0.05 was considered significant. Results: Both the groups were similar with regard to demographic factors (P > 0.05). The visual analog scale scores at rest, deep breathing, coughing and movement, and postoperative fentanyl consumption were similar in the two groups (P > 0.05); the incidence of side effects was also similar in the two groups (P > 0.05). Conclusions: Continuous thoracic PVB is as effective as continuous thoracic EA in providing pain relief in patients undergoing open nephrectomy in the postoperative period. The side effect profile of the two techniques was also similar.

Fluoroscopy-Guided Iliopsoas Injection: A Modified Approach

To the Editor: Myofascial pain in the iliopsoas is a common cause of low back and pelvic pain. Injection of the iliopsoas muscle is a well-known procedure for relieving myofascial pain arising secondary to its involvement. Iliopsoas is a deep muscle, which offers core support to the spine among other musculature. It is composed of the iliacus and psoas muscles. The psoas takes its origin from the T12 vertebra and runs downward, getting muscle fibers from the first 4 lumbar vertebrae, to insert into the lesser trochanter of femur. The iliacus arises from the iliac bone, to attach into the lesser trochanter. The commonly described fluoroscopic technique of injecting the iliopsoas mandates placement of needle at the level of L3 vertebra, 5 cm lateral to the spinous process.

Comparative Evaluation of Retrocrural versus Transaortic Neurolytic Celiac Plexus Block for Pain Relief in Patients with Upper Abdominal Malignancy: A Retrospective Observational Study.

Aim: To compare retrocrural versus transaortic techniques for neurolytic celiac plexus block (NCPB) in patients suffering from upper abdominal malignancy. Methods: In this retrospective observational study between October 2013 and April 2015, 64 patients with inoperable upper abdominal malignancy received fluoroscopy-guided percutaneous NCPB in our institute. Their case files were reviewed and the patients were divided into two groups depending on the technique used to perform NCPB: retrocrural (Group R; n = 36) versus transaortic (Group T; n = 28). The primary outcome measure was pain as assessed with a numeric rating scale (NRS) from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses in each group, and complications if any. These were noted and analyzed prior to intervention and then on day 1, weeks 1, 2, 3, and months 1, 2, 3, 6 following NCPB. Results: Patients in Group R had significantly reduced NRS pain scores at week 1, 2, 3, month 1 and 2 as compared to Group T (P < 0.05). Morphine consumption also reduced significantly in Group R at day 1, week 1, 2, and 3 (P < 0.05). QOL was found to be comparable between the groups, and no major complications were noted. Conclusion: Retrocrural NCPB provides superior pain relief along with a reduction in morphine consumption as compared to transaortic NCPB in patients with pain due to upper abdominal malignancy.