Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine / Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina

Abstract Background and objectives: Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine. Methods: A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S - control group received adductor canal block with 30 mL saline, Group R - ropivacaine group received adductor canal block with 30 mL of 0.375% ropivacaine and Group RC - clonidine group received adductor canal block with 30 mL of 0.375% ropivacaine with clonidine 1 µg.kg-1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting. Results: The mean pain free periods were 20 min, 384.76 min and 558.09 min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement. Conclusion: Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

Resumo Justificativa e objetivos: O alívio inadequado da dor após a reconstrução do ligamento cruzado anterior afeta a mobilidade, leva ao desenvolvimento de aderências, inserção do ligamento enfraquecido e atrofia muscular. O bloqueio do canal adutor para analgesia pós-operatória preserva a força do quadríceps. O presente estudo foi feito para comparar o período sem dor em pacientes de reconstrução artroscópica do ligamento cruzado anterior, submetidos ao bloqueio do canal adutor guiado por ultrassom com ropivacaína isolada e ropivacaína + clonidina. Métodos: Um estudo prospectivo, randômico e duplo-cego foi conduzido com 63 pacientes adultos, estado físico ASA I-II, submetidos à reconstrução do ligamento cruzado anterior. Os pacientes foram randomizados em três grupos: Grupo S, que recebeu bloqueio do canal adutor com 30 mL de solução salina para controle; Grupo R, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375%; Grupo RC, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375% e 1 µg.kg-1 de clonidina. O desfecho primário do estudo foi comparar o período sem dor nos pacientes que receberam bloqueio do canal adutor com ropivacaína isolada ou ropivacina + clonidina. Os desfechos secundários foram escores de dor em repouso e movimento, necessidade total de analgésicos, escore de sedação, além de náusea e vômito no pós-operatório. Resultados: Os períodos médios sem dor foram 20 min, 384,76 min e 558,09 min para os grupos S, R e RC, respectivamente, e essa diferença foi estatisticamente significativa (p < 0,001). Não houve diferença significativa entre os grupos R e RC em termos de escores de dor em repouso e movimento e a necessidade total de analgésicos. Conclusão: A adição de clonidina à ropivacaína em bloqueio do canal adutor guiado por ultrassom levou a um prolongamento significativo do período sem dor, embora os escores de dor em repouso e movimento, e a necessidade de analgésico de resgate, não tenham diferido.

Immunoglobulin G4 related pancreaticobiliary disease: Report of two cases highlighting the diagnostic criteria

Two cases of immunoglobulin (IgG4)-related biliary and pancreaticobiliary disease are reported to define its diagnostic features. Case 1 presented with obstructive jaundice and showed IgG4-related disease (RD) involving right and left hepatic duct, common bile duct and gallbladder. Case 2 presented as periampullary mass. Both patients underwent surgical intervention. However, certain clinical and radiological features were present in these cases indicative of the possibility of IgG4-RD.

Autologous Conditioned Serum as a Novel Alternative Option in the Treatment of Unilateral Lumbar Radiculopathy: A Prospective Study

STUDY DESIGN: The study was conducted on patients who received autologous conditioned serum (ACS) as a line of treatment at the Orthopedics outpatient department of Post Graduate Institute of Medical Education and Research (PGIMER, Chandigarh) from January 2011 to June 2012. Of the 1,224 patients, 20 males or females were included in the study based on the inclusion and exclusion criteria. The institutional board of PGIMER approved the study before it was initiated. PURPOSE: To study the efficacy of ACS in the treatment of unilateral lumbar radiculopathy. OVERVIEW OF LITERATURE: Interleukin (IL)-1 appears to be of special importance among the cytokines identified in orthopedic diseases. ACS contains high concentrations of IL-1 receptor antagonist, antagonist to IL-1 in that is a biochemical 'sensitizer' of nerve roots in radiculopathy. METHODS: We included 20 patients with unilateral lumbar radiculopathy after obtaining informed consent. We prepared ACS as described by Meijer et al. Under bi-planar fluoroscopic imaging in anterior-posterior and lateral views, ACS was administered via epidural perineural technique. Patients in both groups were evaluated by quadruple visual analogue scale, straight leg raising test, revised Oswestry disability index, and 12-Item Short Form of Health Survey before and after epidural injections at 3 weeks, 3 months, and 6 months. RESULTS: There was a statistically significant change in all parameters from pre-injection to first, second, and third follow-up (p<0.001). CONCLUSIONS: ACS can modify the disease course in addition to reducing pain, disability and improving general health.

Clinical relevance of HBV DNA load in patients with chronic hepatitis B infection.

BACKGROUND: Hepatitis B virus (HBV) DNA detection and quantification are now playing an increasing role in the assessment of disease activity and response to therapy. However, viraemia levels which define various stages of HBV infection have not yet been established. AIM: To define viraemia levels which describe various stages of chronic hepatitis B virus infection. METHODS: In a retrospective study, stored sera samples of chronic hepatitis B virus (CHB) infected patients registered at AIIMS liver clinic, from January 1996 to June 2005 were subjected to competitive, quantitative PCR analysis. RESULTS: The median HBV DNA load was lowest among carriers and highest among patients with chronic hepatitis B [0 (0-8) vs. 7 (0-12) log10 copies/ml, respectively; p<0.05]. As compared to chronic hepatitis patients the DNA load was also lower among cirrhotics [7 (0-12) vs. 4.5 (0-8) log10 copies/ml, respectively; p<0.05] and hepatocellular cancer patients [ 7(0-12) vs. 0 (0-8) log10 copies/ml, respectively; p<0.05]. Patients with carriers had a DNA load which was significantly lower than e antigen negative CHB [0 (0-8) vs. 6 (0-10) log10 copies/ml; p<0.05] or e antigen positive CHB [0 (0-8) vs 8 (0-12) log10 copies/ml; p<0.05]. A threshold of 3.5 log10 copies/ml had sensitivity and specificity of 83% and 58% respectively in differentiating carriers from e antigen negative CHB. There was a strong positive correlation of HBV DNA load with inflammatory grade (R=0.334; p=0.0001), fibrosis stage (R=0.276; p=0.001) and ALT levels (R=0.378; p=0.0001). 82% (9/11) of those who lost e antigen had a decline in HBV DNA levels to <5 log10 copies/ml, whereas only 12.5% (1/8) of those who did not lose e antigen had a decline in DNA load below this level. CONCLUSIONS: HBV DNA viraemia levels correlate positively with the inflammatory grade, fibrosis stage and ALT levels. Most patients who loose e antigen have a decline in DNA load to below 5 log10 copies/ml. Further prospective studies employing repeated measurements are required to define a threshold to differentiate between HBV carriers and e antigen negative CHB.

Sedation in patients above 60 years of age undergoing urological surgery under spinal anesthesia: comparison of propofol and midazolam infusions.

CONTEXT: Propofol and midazolam are commonly used sedatives during regional anesthesia in adults. Smaller doses of these drugs are required in older age due to altered pharmacokinetics and pharmacodynamics. AIMS: To study the sedation, side-effects and the costs involved with smaller doses of propofol and midazolam in patients aged above 60 years during spinal anesthesia. SETTINGS AND DESIGN: A randomized single-blind study was conducted in 60 ASA I-II patients aged > or = 60 years undergoing urological surgery under spinal anesthesia. MATERIALS AND METHODS: Sedation was administered after spinal anesthesia using propofol (bolus 0.4 mg.kg -1; infusion 3 mg/kg/hr) or midazolam (bolus 0.02 mg/kg; infusion 0.06 mg.kg -1.h -1) and titrated to achieve a sedation score of 3 on the modified Observer's Assessment of Alertness/Sedation Scale. Perioperative sedation, hemodynamics and respiratory events were monitored. STATISTICAL ANALYSIS: The analysis for parametric data was done using Student's unpaired t test and the incidence data using Chi-square test. RESULTS: The onset (13.0+/-4.2 vs. 18.8+/-4.2 min, P < 0.001) and offset (8.9+/-2.8 vs. 12.5+/-3.5 min, P < 0.001) of sedation were faster and the duration of adequate sedation longer (44.7+/-12.5 vs. 29.8+/-12.9% of total infusion time, P < 0.001) with propofol than midazolam. More patients receiving propofol compared to midazolam had hypotension (16 [50%] vs.4 [14.3%], P= 0.003). Airway obstruction occurred frequently in both the groups. Sedation was significantly more expensive with propofol than midazolam (US$ 9.83 +/- 2.80 vs. US$ 0.33 +/- 0.06, P 0.001). CONCLUSIONS: Propofol provided better titration and adequacy of sedation than midazolam in patients above 60 years of age, but caused hypotension. Lighter sedation is recommended in this age group.

Unusual malignant tracheal tumour presenting with acute airway obstruction.

A 25-year-old male presented with features of acute airways obstruction. He was diagnosed to have a lower tracheal mass with near total tracheal obstruction and complete obstruction of the left main bronchus. The tumour was resected successfully using a two-step method of ventilation. Histopathology of the mass revealed it to be a spindle cell sarcoma. Subsequently, local irradiation and systemic chemotherapy was given.

Radiofrequency ablation: a new therapeutic modality for the management of hepatocellular cancer.

We report two patients of hepatocellular cancer who recently underwent radiofrequency ablation at our center. Both underwent successful ablation of the tumour requiring 1-2 sessions of upto 15 minutes. There were no post procedure complications. One of the patients had developed another lesion after 10 months of follow up and underwent another session of RFA, while the second patient is doing well after one year of the procedure.

A comparative evaluation of thoracic and lumbar epidural fentanyl for post thoracotomy pain.

Thirty patients undergoing closed mitral valvotomy were prospectively randomised to receive either thoracic or lumbar epidural catheter. General anaesthesia consisted of morphine sulphate 0.15 mg/kg (single dose given before skin incision), thiopentone sodium 4-6 mg/kg, vecuronium and halothane titrated to stable haemodynamics. In the immediate postoperative period, pain was assessed by VAS (visual analogue scale) and VRS (verbal ranking score) and an epidural fentanyl bolus of 1.5 microg/kg was given followed by an infusion of 0.4 microg/kg/hr. Pain was assessed after 30 min and if pain relief was still inadequate, another fentanyl bolus of 1 microg/kg was administered, followed by an increase in infusion rate to 0.6 microg/kg/hr. If two consecutive pain scores were satisfactory (VAS <4, VRS <1) maintenance dose of fentanyl was decreased by 0.2 microg/kg/hr. Thoracic group received significantly less total dose of fentanyl in 24 hrs period (446.7 +/- 101.70microg) compared with the lumbar group (705.33 +/- 181.03microg) (p<0.01). The mean infusion rate was also significantly less in the thoracic group as compared with the lumbar group (0.44 +/- 0.08microg/kg/hr vs 0.61 +/- 11microg/kg/hr, p<0.001). The side effects were comparable between both the groups and none of the patients had significant respiratory depression. The data suggest that thoracic epidural fentanyl infusion is superior to lumbar infusion for post thoracotomy pain relief because of smaller dose requirement.

Effects of cardiopulmonary bypass on thyroid function.

Alterations in serum concentration of thyroid hormones occur even in euthyroid patients undergoing cardiopulmonary bypass. The purpose of our prospective study was to define the effects of cardiopulmonary bypass on thyroid hormones. Twenty euthyroid patients for mitral valve replacement were included in this study. Heparinised arterial sample for thyroid function tests were obtained before cardiopulmonary bypass (CPB), 30 and 60 minutes after initiation of CPB, immediate post-CPB and 24 hours after termination of CPB. T3, T4 and thyroid stimulating hormone (TSH) were estimated using radioimmunoassay method. There was more than 50% decrease in T3 levels after initiation of CPB and it remained persistently below the physiological range until 24 hours after termination of CPB. T4 and TSH remained within normal limits throughout the study period. These results indicate that CPB simulates the euthyroid sick syndrome as seen in critically ill and burn patients. Whether routine administration of intravenous tri-iodo thyronine is beneficial in the prevention of low cardiac output syndrome seen after CPB remains to be elucidated in future.

Comparison of the Effects of Sevoflurane and Halothane on Arterial Oxygenation during One Lung Ventilation.

We investigated the effect of halothane and sevoflurane on oxygenation during one lung ventilation (OLV) in 24 patients undergoing elective thoracic procedures. After induction with thiopentone, 4-5 mg/kg and morphine 0.1 mg/kg, suxamethonium 2mg/kg was administered to facilitate tracheal intubation with a double lumen tube. Anaesthesia was maintained with 1.5-3% sevolurane (group 1, n = 12) or 1.1.5% halothane (group 2, n = 12) in 02 with N20 (1:1) and pancuronium bromide. Arterial blood gases were recorded before surgery in the lateral position with two lung ventilation (2LV), 10, 20 and 30 minutes after beginning of one lung ventilation. Morphine and endtidal inhalational anaesthetic concentration were titrated to desired anaesthetic depth and haemodynamic variables. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and central venous pressure (CVP) were measured during the study period. In both the groups there was a significant decrease of PaO2 apparent at 10 minutes after initiation of OLV. Thereafter PaO2 remained stable throughout the study period in both the groups. It is concluded that oxygenation did not differ significantly with either sevoflurane or halothane during OLV. It is also concluded that decrease in oxygenation with OLV is complete by 10 minutes of its initiation.

Sevoflurane for trans-sternal thymectomy in myasthenia gravis.

Myasthenic gravis (MG) is an autoimmune disease associated with acetylcholine receptor deficiency. Patients with MG exhibit increased sensitivity to non-depolarising muscle relaxants. In an attempt to avoid neuromuscular blockers, we used sevoflurane in two myasthenic patients undergoing trans-sternal thymectomy. Inhalation of 8% sevoflurane in oxygen using vital capacity technique produced rapid, pleasant and smooth induction and provided good tracheal intubating conditions. In both patients anaesthesia was maintained with 1.5-2% end-tidal concentration of sevoflurane and nitrous oxide in oxygen without adjunctive neuromuscular blocking agents. There were minimal changes in cardiovascular variables and recovery was faster. It is suggested that sevoflurane may be the main anaesthetic for both induction and maintenance in myasthenic patients undergoing trans-sternal thymectomy.

Comparative evaluation of cardiovascular effects of sevoflurane and isoflurane in patients with ischaemic heart disease undergoing non-cardiac surgery.

Twenty three adult patients with ischaemic heart disease undergoing elective non-cardiac surgery were studied. Induction of anaesthesia was similar for each patient and included thiopentone (4-5 mg/kg), morphine (0.1 mg/kg) and vecuronium (0.1 mg/kg). Additional morphine and vecuronium were used when necessary. All these patients were maintained with either sevoflurane (n=11) or isoflurane (n=12). The inhaled anaesthetics were titrated to achieve adequate clinical 'depth of anaesthsia' and to maintain mean arterial pressure within 20% of the pre-induction values. Heart rate, blood pressure and rate-pressure product were recorded during the maintenance phase of anaesthsia. ST-T changes were also monitored during this period. There was a tendency for heart rates to be significantly higher shortly after skin incision till the end of procedure in the isoflurane group, while in the sevoflurane group heart rate remained stable during the surgical procedure. Both systolic and diastolic blood pressure remained similar in both groups. The rate pressure product was higher in the isoflurane group than in the sevoflurane group at 30 min Post-incision. The data suggests that sevoflurane is not associated with untoward cardiovascular changes in ischaemic heart disease patients undergoing non-cardiac surgery.

Fibreoptic assessment of post intubation laryngotracheal injuries.

The use of endotracheal intubation for respiratory support of critically ill patients has become a standard life saving form of therapy. Most complications of intubation become apparent only after extubation which may manifest in the early or late post extubation period. This study was undertaken to demonstrate the occurrence and extent of laryngotracheal injuries in intubated patients by performing flexible fibreoptic bronchoscopy at varying intervals following extubation. It was found that initial laryngoscopy findings were more pronounced in patients intubated for upto twelve days. Furthermore, it was also observed that the initial laryngeal pathology seen on fibreoptic laryngoscopy was not an accurate predictor for the development of adverse post extubation sequelae. Maxillary sinusitis developed significantly in patients intubated nasally. Routine flexible fibreoptic examination of the larynx following extubation is recommended for early detection of granulomas, synechia of vocal cords and vocal cord immobility to prevent troublesome sequelae.

Infection rates in single- and double-lumen central venous catheters in critically ill patients.

BACKGROUND. Catheter-related sepsis is a well known complication in critically ill patients receiving total parenteral nutrition. Micro-organisms may travel from the skin puncture wound along the external surface of the catheter or from the hub through the lumen of the catheter, to be shed into the circulation causing bacteraemia and sepsis. The incidence of sepsis is said to be about three times greater with multiple-lumen catheters than with single-lumen catheters. METHODS. Fifty patients admitted to our intensive care unit were randomly assigned to have either a single-lumen (Group I, 25 patients) or double-lumen (Group II, 25 patients) hydromer-coated, polyurethane central venous catheters of the same gauge and length, placed through the infraclavicular subclavian approach using the Seldinger technique. A sterile dry gauze dressing at the skin puncture site was changed every day. Skin swabs were taken for semi-quantitative culture studies before catheter insertion and removal, from the proximal 3 cm (lying subcutaneously) and distal 5 cm of the catheter segments on removal of the catheter, and venous blood was drawn from a peripheral vein before removal of the catheter. RESULTS. The most common isolate was coagulase negative Staphylococcus. No significant difference was found between the two groups in the incidence of catheter-related infection and catheter-related sepsis. CONCLUSION. Double-lumen central venous catheters placed in critically ill patients do not cause more sepsis than single-lumen catheters.

Role of mechanical ventilation in acute severe asthma.

During the last 4 years, fifty-seven patients of acute severe asthma (ASA) were admitted to intensive care unit (ICU). Twenty-three patients required mechanical ventilation (MV) on 25 occasions. Indications to intubate were persistent hypoxia (PaO2 < or = 55 mm Hg) or hypercapnia with respiratory acidosis (64%), abnormal mentation (24%) and respiratory arrest (12%). All the patients were monitored for clinical features, arterial blood gases (ABG) and peak airway pressure (PAP). During MV, there was one case of pneumothorax (4%), seven (28%) cases of transient hypertension and one (4%) patient died. Mean duration of MV was 3 days and the outcome was favourable. Therefore, resorting to aggressive treatment early in the course of disease proves life saving in acute severe asthma.

Domiciliary mechanical ventilation in a patient with severe chronic obstructive lung disease and respiratory failure.

A patient of chronic obstructive pulmonary disease (COPD) with cor-pulmonale and chronic respiratory failure, who was given intermittent positive pressure ventilation at home, is reported. The patient did remarkably well on home mechanical ventilatory support. We believe this to be the first case report of domiciliary mechanical ventilation in a patient of COPD from India.

Serum potassium levels following suxamethonium administration in septic peritonitis patients.

Serum potassium and sodium changes following suxamethonium (1.5 mg/kg) administration were studied in 25 patients with septic peritonitis and 25 with no signs of peritonitis. A highly significant rise (P less than 0.001) in serum potassium (0.1-2.5 mEq/l) above the pre-induction levels was observed following suxamethonium administration in patients with septic peritonitis with maximum rise at 5 min following suxamethonium. This rise in potassium was significantly higher (P less than 0.001) in peritonitis patients at 3,5, and 10 min interval. A positive correlation was found between rise of potassium and duration of illness (P less than 0.01). No statistically significant changes were observed in serum sodium levels in both groups.