A Double Blind Comparative Study between Intrathecal Bupivacaine and Intrathecal Fentanyl as the Initial Dose of Combined Spinal Epidural Technique for Labour Analgesia

Introduction: Labour analgesia techniques is the mostwidely practised procedures of pain management performedby an anaesthesiologist and are requested by the obstetriciancolleagues as well as the parturient mothers. Presently,Combined Spinal Epidural (CSE) is the most popular andeffective technique of Labour Analgesia to render the motherpain free. This technique has two parts. Our study is primarilyconcerned with the first part of CSE for the comparison ofdrugs. The aim of the study was to compare the efficacybetween a small and fixed doses Fentanyl (25μgm) andHyperbaric 0.5% Bupivacaine (2.5mg) as the initial step ofCSE technique for labour analgesia.Material and methods: This double blind study aims tocompare the efficacy between a intrathecal fixed dose oflipophilic opioid i.e, Fentanyl (25μgm) and a fixed dose oflocal anaesthetic hyperbaric 0.5% Bupivacaine ( 2.5mg) as theinitial step to establish labour analgesia . 60 parturient willbe divided into two group. Group I will receive intrathecalFentanyl and Group II will receive intrathecal Bupivacaine.Onset, quality and quantity of pain relief achieved followingintrathecal injection of drugs will be taken into account whereasincidence of side-effects like motor paralysis, hypotension,pruritus, foetal bradycardia & respiratory depression willbe noted and compared. This will indicate which drug willbe more preferable as a sole drug for the initial intrathecalcomponent of CSE technique for labour analgesia.Results: The shortest time of onset of analgesia in group Iwas 60sec and in group II was 40sec which was statisticallysignificant (p<0.05). The average duration to reach maximumanalgesia in Group I was 5.93 ± 1.68 min and in Group IIwas 5.30 ± 1.31 min.Whereas the duration of analgesia wasfound varying widely. It was 54±15.16 minutes in Group Iwhereas 73.5±14.74 minutes in Group II. The duration rangedfrom 25 minutes to 80 minutes in Group I and 35 minutesto 100 minutes in Group II. This difference was statisticallysignificant (p=0.000005).The significant side effect noted waspruritus (56.67%) in Group I and motor paralysis (80%) andhypotension (6.67%) in Group II.Conclusion: A small dose of Fentanyl is preferable to asimilar small dose of Bupivacaine for the initial intrathecaladministration as a part of Combined Spinal Epidurallabour analgesia technique as muscle weakness prevents themother from taking active part in second stage of labour andhypotension is non desirable.

Systemic fungal infections in renal diseases.

Invasive fungal infections are a major challenge in the management of immunocompromised patients and those with renal dysfunction. These challenges are due to the immense morbidity and mortality in such situations. Also the management strategies for invasive mycosis in patients with renal dysfunction have narrow safety profile and involve high-cost. In this review we will discuss the issues involved in the management of invasive mycosis in the patients with renal dysfunction in the form of acute renal failure, chronic kidney disease, dialysis dependency of renal transplant recipients. We also emphasize that the use of Intravenous Liposomal Amphoterecin appears to be an effective alternative to the conventional Amphoterecin B for the treatment of invasive fungal infections in patients with renal dysfunction due to its greatly improved tolerability profile. Commercially two true liposomal preparations (Fungisome and Ambisome) are available. Judgement about the preferred formulation should be made on the basis of disease morbidity, severity of renal dysfunction and the cost involved.

Protein intake in Indian haemodialysis patients.

OBJECTIVES: Aim of our study was to find out the amount of protein consumed by Indian haemodialysis patients. METHODS: Twenty patients with endstage renal disease on regular haemodialysis at a major urban dialysis centre in India had their Kt/V and nPCR measured monthly for 4 months utilising urea kinetic methods. RESULTS: Despite an adequate amount of dialysis per session being delivered to almost all of these patients (19 out of 20 had a Kt/V greater than 1.2) none of our patients had an nPCR greater than 1 gm/kg/day and only 4 patients i.e. 20% had a protein intake greater than 0.8 gm/kg/day which is a cut off point below which mortality has been shown to increase dramatically. Most of the patients had a protein intake between 0.7-0.8 gm/kg/day which is alarmingly low. Patients who consumed non vegetarian food at least thrice a week did appear to have a significantly higher protein intake compared to the rest of the patients. CONCLUSION: We believe that these results are likely to be representative of other dialysis centers in India and that an intensive effort at dietary education aimed at increasing the protein intake in our haemodialysis patients is urgently required. The morbidity and mortality of dialysis patients is high and perhaps appropriate dietary intervention can help to reduce this.

Can general practitioners carry out drug delivery and periodic examination of leprosy patients in Raipur city?

An intervention study to improve the MDT coverage of leprosy patients by involving general practitioners (GPs) was carried out in Raipur city. Most of the GPs (84%) were willing to undertake drug delivery and periodic examination of the leprosy patients. After involving GPs, the proportion of the patients registered for treatment increased from 33% to 89.2%. The cohort regularity was 57% only which was lower than that found in the Upgraded Urban Leprosy Centre. Drug compliance as found out by the pill count was 91%. Most of the patients (87%) were happy with the services provided by the GPs.

Two unusual cases of foreign body larynx.

Two adult patients of foreign body larynx who presented to us with a short history of foreign body inhalation with severe respiratory distress are being reported. They underwent elective tracheostomy preoperatively for maintenance of airway and the foreign body was removed successfully. We conclude that preoperative tracheostomy can be attempted to secure a patient's airway before resorting to removal of foreign body lodged in the larynx.

Plasma lipid profile in gallstone patients from North India.

One hundred and thirty five patients with gallstones along with eighty nine matched controls were studied ultrasonographically to look for any association with hyperlipidemias. Plasma cholesterol and triglycerides were estimated by colorimetric methods and lipoproteins were classified according to Beaumont's classification. Male to female ratio in gallstone patients was 1:3. Mean plasma cholesterol and triglyceride values were higher in male gallstones patients as compared to controls (166.40 +/- 54.21 vs 40.26 +/- 32.80 mg/dl, p <0.01 and 182.65 +/- 84.49 vs 133.18 +/- 52.37 mg/dl, p <0.01 respectively). In female gallstone patients, on the other hand, only plasma triglyceride levels were raised as compared to control (182.65 +/- 84.49 vs 133.18 +/- 52.32 mg/dl, p <0.01). Prevalence of type IIb and type IV was 24.32% and 29.72% in male gallstone patients and 13.2 and 39.70% respectively in female gallstone patients. Thus, more than half of our gallstone patients had hyperlipidemia, the commonest types amongst them being type IIb and type IV.

Thyroid hormones in diabetic ketoacidosis before and after therapy.

Fifteen IDDM patients were evaluated for thyroid hormone abnormalities before and after control of diabetes mellitus/ketoacidosis. Blood sugar mean +/- SEM mg/dl on admission was 430 +/- 20.3 and after therapy fasting and post prandial blood sugar values were 120 +/- 14.5 and 150 +/- 20.2 respectively. GHb mean +/- SEM % on admission was 15.2 +/- 0.36. Serum T3 mean +/- SEM ng/dl of 0.36 +/- 0.04 was in hypothyroid range and rT3 mean +/- SEM ng/ml 0.40 +/- 0.6 was significantly raised (P < 0.001) before therapy. After metabolic control both T3 and rT3 became normal. T4 concentration mean +/- SEM meg/dl of 5.5 +/- 0.7 was well within normal range before therapy and rose to mean +/- SEM mcg/dl 8.8 +/- 0.5 after therapy (P < 0.01). TSH response to TRH was blunted in uncontrolled state. It is concluded that peripheral changes in T3, T4 and rT3 (low T3, high rT3 and low or normal T4) occurred in uncontrolled diabetic state during ketoacidosis. TSH response to TRH was blunted due to suppression of hypothalamic pituitary thyroid axis which takes more than a week for complete recovery.

A simple spot-test for circulating Entamoeba histolytica antigen-antibody complexes in patients with amoebic liver abscess.

An enzyme linked immunosorbent assay (ELISA) is described for the detection of E. histolytica immune complexes in serum. Antiamoebic antibody purified by affinity chromatography was used both to precoat strips of nitrocellulose membrane and as an enzyme carrier. These strips were incubated with samples of concentrated test serum and the enzyme conjugate. Following treatment with the peroxidase substrate 3-amino-9-ethylcarbazole the presence of E. histolytica antigens was visualized as red spots. Blocking of positive test sera with excess antibodies inhibited this reaction. Serum samples from 47 patients with amoebic liver abscess, 43 patients with other enteric diseases and 35 healthy controls were investigated. The spot test was positive in 75 per cent of patients with amoebic liver abscess, and in 12 per cent diseased controls whereas all the healthy controls were negative. The spot test is simple and sensitive and does not require prior separation of the immune complexes. The test is recommended as an aid to the diagnosis in patients suspected to have amoebic liver abscess.

Lipids changes in alcoholic & non-alcoholic cirrhotics.

Fasting plasma samples from 29 patients of cirrhosis were analysed for cholesterol and triglycerides and their lipo-protein fractions. The patients included 11 alcoholic cirrhotics consuming over 130 g/day of absolute ethanol and 18 non-alcoholic cirrhotics. The difference in lipid values between the two patient groups was not significant except that VLDL cholesterol was raised in alcoholic cirrhotics (P less than 0.05). However, in comparison to normal healthy controls, the values were significantly altered. The dietary intake, in the two groups showed no difference, except that non-alcoholic cirrhotics consumed more animal proteins. Low intake of exogenous fat and reduced synthesis of endogenous cholesterol in cirrhotic patients seemed to influence the total lipid values.

Serological pattern of hepatitis B virus markers (HBsAg, anti-HBs, IgM anti-HBc and HBV specific DNA polymerase) in leprosy patients.

Sera of 134 lepromatous (LL/BL) and 57 tuberculoid (TT/BT) leprosy patients were analysed for four HBV markers. HBsAg was detected in 6.71% of lepromatous and 3.5% of tuberculoid sera. The per cent positivity of lepromatous and tuberculoid sera for anti-HBs antibodies was 30.59% and 35.08%, respectively. The positivity of normal sera for HBsAg and anti-HBs was 3.60% and 21.69%, respectively. The difference in the positivity of three groups of sera (lepromatous, tuberculoid and normal) for HBsAg or anti-HBs was not statistically significant. Anti-HBc (IgM) antibodies were detected in 6% of lepromatous sera. HBV-specific DNA-polymerase activity was found in 22.22% of HBsAg positive (but anti-HBc negative) sera, and 66.66% of anti-HBc positive (but HBsAg negative) sera. The pattern of acute HBV infection in leprosy patients followed the typical pattern prevalent in the normal population.

Role of immune serum globulin in post transfusion virus B infection.

Fifty four blood recipients were administered prophylactic immune serum globulin (31) or hepatitis B immune globulin (23) and followed up for six months. None of the patients developed either acute hepatitis B or HBsAg carrier state. However, 7 (14%) had anicteric self limiting non-B post-transfusion hepatitis. Twenty (40%) of the blood recipients developed anti-HBs during the follow up period suggesting either HBV exposure by subdetectable levels of HBsAg present either in blood or immunoglobulin preparation or due to passive transfer by administration of immunoglobulins.