Sukhyanti Kerai

Role of transcutaneous electrical nerve stimulation in post-operative analgesia.

The use of transcutaneous electrical nerve stimulation (TENS) as non-pharmacological therapeutic modality is increasing. The types of TENS used clinically are conventional TENS, acupuncture TENS and intense TENS. Their working is believed to be based on gate control theory of pain and activation of endogenous opioids. TENS has been used in anaesthesia for treatment of post-operative analgesia, post-operative nausea vomiting and labour analgesia. Evidence to support analgesic efficacy of TENS is ambiguous. A systematic search of literature on PubMed and Cochrane Library from July 2012 to January 2014 identified a total of eight clinical trials investigating post-operative analgesic effects of TENS including a total of 442 patients. Most of the studies have demonstrated clinically significant reduction in pain intensity and supplemental analgesic requirement. However, these trials vary in TENS parameters used that is, duration, intensity, frequency of stimulation and location of electrodes. Further studies with adequate sample size and good methodological design are warranted to establish general recommendation for use of TENS for post-operative pain.

Klippel-Feil syndrome and neuraxial anaesthesia.

Klippel-Feil syndrome (KFS) is an uncommon congenital disorder characterised by fusion of two or more cervical vertebrae. The perioperative anaesthetic management in these patients is complicated by anatomical changes, which presupposes the presence of difficult airway and by presence of multiple associated congenital anomalies. Literature search for anaesthetic management of KFS patient showed paucity of reports employing neuraxial technique.

Comparative evaluation of transversus abdominis plane block with transcutaneous electrical nerve stimulation for postoperative analgesia following lower segment caesarean section

Background : Pain relief after caesarean is more compelling than any other surgery. As most commonly used modalities are associated with various side-effects, a multimodal approach is recommended. Transversus abdominis plane (TAP) block and transcutaneous electrical nerve stimulation (TENS) as part of multimodal postoperative analgesia regimes have been shown to be promising following caesarean section. Materials and Methods : 40 patients undergoing caesarean section under spinal anaesthesia were randomly allocated into 2 groups, first group receiving TAP block and second receiving TENS. In postoperative period pain, nausea and vomiting, sedation was recorded at 30 minutes, 2, 4, 6, 12 and 24 hours. Results : Both TAP block and TENS were effective for post caesarean analgesia as a part of multimodal regimen. In both groups VAS was less than 3 at each time interval. None of the patients required rescue analgesia. There was no complication with TAP block. Three patients in TENS group complained of discomfort and apprehension because of tingling sensation of TENS. Conclusion : Both TAP block and TENS as a part of multimodal analgesia are effective following caesarean delivery. Both decrease requirement of opioids and thus associated side effects as a result of which the mother is able to care for baby more effectively.

Amlodipine toxicity complicated by concurrent medications

tion in patients with hypertension. Cases of amlodipine toxicity have been reported in literature. We report a rare case of 45 year old female with alleged history of suicide with amlodipine, and other medications which included sedatives, anti-hypertensives, oral hypoglycemic agents and thyroid medications. Our patient presented with atypical features of poisoning and hence was managed accordingly. The clinical picture at the time of presentation and management has been described in detail. Amlodipine is a type of dihydropyridine calcium channel blocker and is used in management of angina pectoris and essential hypertension. It is prescribed as a daily dose of 5–10 mg daily. There are reported cases of amlodipine toxicity in literature, however none described a case of amlodipine toxicity complicated with other concurrent medications. We report a well-managed case of severe amlodipine intoxication complicated by other medications. A 45-year-old woman with chronic hypertension, diabetes, hypothyroidism, coronary artery disease, and depression had been taking amlodipine 5 mg once daily (OD), telmisartan 40 mg OD, metformin 500 mg twice daily (BID), glimepiride 2 mg BID, levothyroxine 100 μg OD, and alprazolam 0.5 mg at bedtime. She was admitted in an unconscious state, with an alleged suicide attempt by taking ten 5-mg tablets of amlodipine in addition to her usual telmisartan, metformin, alprazolam, and levothyroxine tablets at bedtime. Her history was provided by her son, and an empty tablet container was retrieved. She was admitted to the emergency department in an unconscious, diaphoretic state, with frothing from the mouth and tongue biting. She was drowsy, with a weak pulse, heart rate of 35 beats/min, systolic blood pressure of 85 mmHg, peripheral oxygen saturation (SpO2) of 40%–50%, and bilateral basal crepitus. Pupils were equally reactive, and she had oliguria (urine output: 30 ml/h). Relatives reported she had an episode of vomiting, followed by rigidity of limbs and a possible seizure. A 7.5 Fr endotracheal tube was immediately inserted and gastric lavage was performed with activated charcoal via gastric tube. She was also administered a bolus of atropine. Her blood sugar was 60 mg/dl, and she was given 100 ml of 25% dextrose over 20 min. She was subsequently transferred to the intensive care unit (ICU). In the ICU, her pulse rate was 45 /min, with blood pressure of 100/70 mmHg and SpO2 of 96%. Calcium and magnesium levels, arterial blood gases, an electrocardiogram, creatine phosphokinase (CPK, total and MB) and troponin T levels, and a chest X-ray were obtained. She was empirically given a bolus of calcium gluconate (10%; 30 ml over 10 min), followed by a 10 ml/h infusion, and a loading dose of phenytoin was given. She had a normal blood count, and urea, creatinine, CPK-MB, and troponin T levels were negative. Fig. 1 shows the chest X-ray with a possible right lower lobe infiltrate. Ionized calcium and blood sugar levels were maintained in the reference range and monitored every hour. She was uneventfully extubated 12 h after poisoning and maintained normal consciousness, vital signs, and urine output. Her oliguria responded to fluid boluses. After extubation, she required highflow nasal oxygen to maintain saturation and had tachypnea of 35 breaths/min, with a resolution after 96 h. Echocardiography and non-contrast brain computed tomography were normal. Over a period of 5 days, her clinical condition improved, and she was moved to a ward and discharged after a few days. She has been followed in the psychiatric clinic for her suicidal behavior. Amlodipine is typically known to produce fewer side efLetter to the Editor

Quadratus lumborum block for post-caesarean analgesia

There are two studies on QLB for post‐operative analgesia after caesarean section, and both reported QLB to significantly reduce morphine consumption in combination with multimodal analgesia regime.[1,2] In both the studies, posterior approach for QLB was used with the patient in the supine position. The advantages of the posterior approach compared to anterolateral and transmuscular approach are more superficial point of injection, better ultrasonographic resolution and potentially safer injection as intraperitoneal contents are at a further distance.[1] Compared to transversus abdominis plane (TAP) block, QLB has been noted to provide widespread analgesia of longer duration. The sensory levels obtained by QLB were T7 and T12 dermatomes, whereas TAP block affected T10 and T12 dermatomes. This can be explained by spread either in the thoracolumbar plane or into the paravertebral space. The extensive spread has been postulated to provide analgesia for visceral component of pain along with somatic. The duration of analgesia after QLB exceeded 24 h and was significantly longer than that for TAP block.[2] However, the post‐operative analgesic regime in both studies included patient‐controlled analgesia morphine and the cumulative consumption measured at various intervals could have been affected by use of morphine for non‐operative pain. Further studies are required for validation of analgesic efficacy of QLB. Another important consideration is that QLB is purely an ultrasound‐guided block and requires a clear knowledge of anatomy for safe performance. A number of vital structures including the kidney and lumbar arteries running behind QL muscle are susceptible to injury. In patients receiving anticoagulant therapy, the QLB should be carefully considered due to the vascularity of area, retroperitoneal spread of haematoma and proximity to paravertebral area and lumbar plexus.[3]

Post-caesarean analgesia: What is new?

Adequate post-operative analgesia after caesarean section (CS) is vital as it impacts the distinct surgical recovery requirements of the parturient. Although newer analgesic modalities and drugs for post-caesarean analgesia have been introduced over the recent years, review of the literature suggests suggests that we are far from achieving the goals of optimum post-operative analgesia. We conducted a systematic review of recent advances in modalities for post-caesarean analgesia. After systematic search and quality assessment of studies, we included a total of 51 randomised controlled trials that evaluated the role of opioids, transversus abdominis plane (TAP) block, wound infiltration/infusion, ketamine, gabapentin and ilioinguinal-iliohypogastric nerve block (II-IH NB) for post-caesarean analgesia. Administration of opioids still remains the gold standard for post-operative analgesia, but the associated troublesome side effects have led to the mandatory incorporation of non-opioid analgesics in post-CS analgesia regime. Among the non-opioid techniques, TAP block is the most investigated modality of the last decade. The analgesic efficacy of TAP block as a part of multimodal analgesia is established in post-CS cases where intrathecal morphine is not employed and in CS under general anaesthesia. Among non-steroidal anti-inflammatory drugs, COX-I inhibitors and intravenous paracetamol are found to be useful in post-operative analgesic regimen. The perioperative use of ketamine is found useful only in CS done under spinal anaesthesia; no benefit is seen where general anaesthesia is employed. Wound infiltration with local anaesthetics, systemic gabapentin and II-IH NB need further trials to assess their efficacy.

Anesthetic management of a patient with Montgomery t-tube in-situ for direct laryngoscopy

The Montgomery silicone t-tube used for post-procedural tracheal stenosis has advantage of acting as both stent and tracheostomy tube. The anesthetic management of patient with t-tube in situ poses a challenge. Safe management of such patients requires careful planning. We describe anesthetic management for direct laryngoscopy of a patient with t-tube in situ.

Is irrational use of intralipid emulsion justified in amlodipine toxicity

highlighting the importance of intra-lipid emulsion (ILE) in amlodipine toxicity, suggested for the management of a case of amlodipine toxicity with concurrent medications, published in the Korean Journal of Anesthesiology [2], we would like to highlight a few points related to the effectiveness of ILE in amlodipine toxicity. Intra-lipid 20% is an intravenous emulsion of fat, administered to patients requiring parenteral nutrition as a source of calories and essential fatty acids. Its role in management of life-threatening cardiac arrest because of local anesthetic (especially bupivacaine) toxicity is well-documented; however, its role in the management of toxicity due to other lipophilic drugs, such as non-local anesthetic drugs, amitriptyline, calcium channel blockers, and baclofen, is not well-established, and most of the literature is based on published case reports [3]. Amlodipine toxicity is associated with significant morbidity and mortality, and the recommended first line therapy for symptomatic patients with calcium channel blocker (CCB) toxicity includes intravenous calcium, high dose of insulin in case of myocardial dysfunction, nor-epinephrine or epinephrine for vasodilatory shock, dobutamine for cardiogenic shock, and atropine in case of symptomatic bradycardia or conduction disturbances. Intravenous calcium is the recommended first line treatment as it improves contractility and blood pressure, carries little risk, and is a readily available drug. High dose of insulin is also known to improve contractility, increase blood pressure, and improve survival, according to observational studies, case series, and animal studies [4]. Recommendation to use ILE is neutral in cases of cardiac arrest due to CCB toxicity (diltiazem, verapamil, and dihydropyridines); ILE should not be used as the first line therapy in life-threatening or non-life-threatening toxicity due to CCBs (level of recommendation: 2D) [3]. The rationale of not using ILE as first line in CCB toxicity is because of inconsistent reported outcomes, including sudden deaths as immediate response, observed in human case reports and animal experiments; therefore, no clear recommendation of its use exists [3]. There are frequent known adverse effects of ILE which occur as a result of contamination of intravenous lines and vein irritation, both of which are not life-threatening. However, less frequent immediate reactions have been reported, including dyspnea; cyanosis; allergic reactions; headache; increase in temperature; chest-pain; flushing; dizziness; and delayed reactions such as jaundice, thrombocytopenia, focal seizure, splenomegaly, and shock [3]. Its administration is contraindicated in patients with disturbance of normal fat metabolism, such as hyperlipidemia and lipoid nephrosis [4]. Moreover, it has been postulated that ILE can enhance intestinal absorption of other toxins, thereby enhancing their effects, as suggested by oral drug poisoning models [4]. Concern has also been raised that concurrent administration of ILE with extracorporeal assist devices interferes with resuscitative medications. A study has also demonstrated worse outcome with verapamil when ILE was administered [5]. Although ILE is not recommended as the first line therapy, it is reserved as rescue therapy in refractory cases which cannot be managed with supportive measures. Step-wise management in case of CCB toxicity is summarized in Fig. 1, as adapted from “Experts consensus recommendations for management of calcium channel blocker poisoning in adults” [4]. Administration Letter to the Editor

Use of Merocel® aids in prevention of nasal pressure ulcers following nasal intubation: Case series of 33 patients

Nasotracheal intubation is the preferred route of airway management for oral and maxillofacial surgeries.[1] Nasal pressure ulcers are a frequently overlooked complication of this technique, especially in cases where intubation is required for a prolonged period. The necrosis can lead to cosmetic and functional disability that may require prolonged medical care and even surgical correction. It may also raise medicolegal problems. Techniques described in the literature to reduce the risk of alar necrosis include the use of hydrocolloid dressing, polyvinyl alcohol foam, DynaplastTM and modified endotracheal tube (ETT).[2-5] We evaluated the efficacy of the use of polyvinyl alcohol foam dressings to prevent nasal alar necrosis in patients requiring prolonged nasotracheal intubation for surgeries for oral and maxillofacial carcinoma.

Airway management in Hurler's syndrome: A persistent challenge for anaesthesiologists

The difficulty in airway management of Hurlers syndrome or mucopolysaccharidosis (MPS) type I patients has been described as the worst.[1] These patients may develop serious complications under anaesthesia including airway obstruction leading to severe hypoxaemia, inability to ventilate or intubate and post-extubation problems.[2] Despite many potential benefits of using supraglottic devices for primary airway management in these patients over endotracheal tube (ETT) intubation, their usage has been limited. We at our centre decided to insert a Proseal laryngeal mask airway (PLMA) in awake state in a patient of Hurler syndrome to circumvent the problem of the difficult airway.