Preemptive Oral Gabapentin and Pregabilin for Post- Operative Pain Management after Surgery under Spinal Subarachnoid Block.

Background: Pregabalin has been used and found effective in preventing neuropathic component of acute nociceptive pain during and after surgery. We conducted a study to compare the effect of oral gabapentin and pregabalin on different block characteristics. Methods: A total of 90 ASA grade I and II patients posted for elective surgeries were randomized into 3 groups (groups A, B and C 30 patients each). One hour before entering into the operation theatre the blinded drug selected for the study was given with a sip of water. Group A – received identical placebo capsule, Group B-received 600 mg of gabapentin capsule and Group C- received 150 mg of pregabalin capsule. Spinal anaesthesia was performed at the L3-L4 interspace. 3.5 ml of 0.5% bupivacaine heavy injected over 30 sec through a 25 G spinal needle. VAS score at first rescue analgesia, mean time of onset of analgesia, level of sensory block at 5 min and 10 min interval, onset of motor block, total duration of analgesia and total requirement of rescue analgesia were observed. Hemodynamics parameters and side effects were recorded in all patients. Results: A significantly longer mean duration of effective analgesia in group C was observed compared with other groups (p<0.001). The mean duration of effective analgesia in group C was 535.16 ± 32.86 min versus 151.83 ±16. 21 minutes in group A and 302.00 ± 24.26 minutes in group B. The mean numbers of doses of rescue analgesia in the first 24 hours in group A, B and C were 4.7 ± 0.65, 4.1 ± 0.66 and 3.9 ± 0.614 respectively. (P value <0.001). Conclusion: We conclude that pre-emptive use of gabapentin 600mg and pregabalin 150 mg orally significantly reduces the postoperative rescue analgesic requirement and increases the duration of postoperative analgesia in patients undergoing elective surgeries under spinal anaesthesia.

A Comparison of Intrathecal Dexmedetomidine and Fentanyl as Adjuvants to Hyperbaric Bupivacaine for Lower Limb Surgery: A Double Blind Controlled Study.

Background: The aim of this study is to compare the effects of Dexmedetomidine and Fentanyl as intrathecal adjuvant to Bupivacaine on the onset and duration of sensory and motor block in orthopaedic lower limb surgeries. Methods: Ninety patients of ASA status I and II posted for lower limb surgery were randomly divided into three groups. Group D was administered Hyperbaric Bupivacaine 15 mg + Dexmedetomidine 5μg in 0.5 ml normal saline, group F was administered Hyperbaric Bupivacaine 15 mg + Fentanyl 25 μg in 0.5 ml normal saline and group C were administered Hyperbaric Bupivacaine 15 mg plus in 0.5 ml normal saline. Duration and quality of sensory and motor block were assessed. Results: Sensory and motor block in-group D patients were longer than group F and C patients. Conclusion: Intrathecal dexmedetomidine when added to bupivacaine heavy (0.5%) provide better and prolonged analgesia in comparison to fentanyl.

Dexmedetomidine and clonidine as an adjuvant to epidural anaesthesia: A prospective randomized, double blind study of their effect on postoperative sensory and motor block characteristics.

Background: Many researchers have been done to find an ideal adjuvant to ropivacaine in regional anaesthesia that inhibits intra and post-operative pain and prolong the duration of anaesthesia without any side effects. Aim: This study was conducted to evaluate the onset, extent and duration of sensory and motor block and side effects of clonidine or dexmedetomidine when used as an adjuvant to ropivacaine in epidural anaesthesia in lower limb orthopaedic surgery. Methods: A prospective randomized study was conducted on 60 patients of American society of anaesthesiologists’ status I and II, posted for lower limb orthopaedic surgery. All patients were randomly allocated into two groups of 30 each; group I was ropivacaine - clonidine group (RC) and group II was ropivacaine - dexmedetomidine group (RD). Group I (RC) patients received 16 ml of 0.75% ropivacaine and clonidine 2 mcg/kg. Group II (RD) patients received 16 ml of 0.75% ropivacaine and dexmedetomidine 1.5 mcg/kg. The onset, extent, duration of sensory and motor blocks, and side effects were recorded. Results: Dexmedetomidine had a visible edge over clonidine as it enabled an earlier onset and longer duration of sensory and motor block. Sedation scores were statistically significant with the RD group in comparison to RC group. The RD group showed visible superiority over the RC group in various post-operative block characteristics like the weaning of sensory and motor block, prolonged post-operative analgesia. Conclusion: Dexmedetomidine was a better alternative to clonidine as an adjuvant to ropivacaine in epidural anaesthesia in orthopaedic lower limb surgeries.

The Effects of Two Different Doses of Clonidine as Adjuvant to Ropivacaine in Supraclavicular Brachial Plexus Block- A Randomized Controlled Study.

Background: Several clinical studies have shown that clonidine prolongs sensory motor blockade when used with bupivacaine but ideal doses of clonidine on ropivacaine is not well defined and to evaluate the effect of two doses of clonidine on ropivacaine, for supraclavicular brachial plexus blockade. Methods: In a prospective randomized double blind study supraclavicular brachial plexus blockade were performed in 80 patients using 35 ml ropivacaine (0.5%). Group A (n=40) had 2 μg/kg clonidine and in Group B (n=40) 1 μg/kg clonidine added to ropivacaine. Sensory and motor blockade was assessed every 5 min till 30 min and at 15 min interval thereafter. Results: Mean sensory onset time in group A was 10.42 ± 5.5 min and in group B was 15.83 ± 6.51 min, which was statistically significant. Patients of group A had a mean motor onset time 14.35 ± 7.8 min and patients of group B had a mean motor onset time 18.53 ± 7.61 min, the difference being statistically significant. Mean duration of sensory block in group A was 484.13 ± 63.1 min and in group B was 390.83 ± 72.63 min, which was statistically significant. Patients in-group A had a mean duration of motor block 550 +60.1 min and patients in group B had a mean duration of motor block 430.43+68.5 min, which was statistically significant. Conclusion: The addition of clonidine in dose of 2 μg/kg to ropivacaine for brachial plexus blockade, increases the onset and duration of motor and sensory block significantly.

Transcatheter Intervention for Infantile Hepatic Hemangioendothelioma with Amplatzer Duct Occluder II.

Introduction: Infantile Hepatic hemangioendothelioma is characterized by multifocal benign vascular dilatations involving the liver. The clinical course depends on tumor size, localization and complications. Case Report: 15 days old neonate with stormy postnatal period was referred for intractable congestive cardiac failure. Transthoracic 2D echocardiography showed multiple vegetations on all the four valves, noncompaction of left ventricle with multiple vascular channels in left lobe of liver. Computed tomography angiogram showed 58x29x50 mm markedly enhancing lesion in left lobe of liver suggestive of infantile hepatic hemangioendothelioma. The neonate was treated for bacterial endocarditis. Later 6x6 Amplatzer duct occluder II was parked in hepatic vein, then gel foam and polyvinyl chloride particles were injected into infantile hepatic hemangioendothelioma. Cardiac failure resolved with marked regression of lesion. Discussion: Infantile hepatic hemangioendothelioma is a rare anomaly causing heart failure in neonate causing death in up to 70% of untreated infants without adequate regression of lesion. Therefore aggressive treatment is warranted. For the first time in the world, we report a case of infantile hepatic hemangioendothelioma in a neonate, with pump failure due to noncompaction of left ventricle and vegetations on all four valves, successfully treated by combination of transcatheter deployment of Amplatzer duct occluder II to occlude the venous end and hand injection of gel foam and polyvinly chloride particles from the aortic end to close the feeder artery. Conclusion: The combination of closure of hepatic vein by Amplatzer duct occluder II and injection of gel foam and polyvinyl chloride particles is safe and effective in infantile hepatic hemangioendothelioma in neonate with heart failure.

Short term efficacy and safety of low dose tolvaptan in patients with acute decompensated heart failure with hyponatremia: a prospective observational pilot study from a single center in South India

In acute decompensated heart failure [ADHF], diuretic use, the mainstay therapy for congestion, is associated with electrolyte abnormalities and worsening renal function. Vasopressin mediates fluid retention in heart failure. In contrast to diuretics, the vasopressin antagonist tolvaptan may increase net volume loss in heart failure without adversely affecting electrolytes and renal function. Hyponatremia [serum sodium concentration, <135 mEq/L] is a predictor of death among patients with heart failure. We prospectively observed the short term efficacy and safety of low dose [15 mg] tolvaptan in admitted patients with hyponatremia and ADHF in Indian population. A total of 40 patients with ADHF along with hyponatremia [<125 mEq/L] on standard therapy were treated with 15 mg of tolvaptan at a single oral dose for 7 days. Serum sodium concentrations increased significantly after treatment with tolvaptan from baseline [P < 0.02]. There was a significant improvement in symptoms and New York Heart Association [NYHA] class after starting tolvaptan [P

Post thyroidectomy complications: the Hyderabad experience

Thyroidectomy is a very common surgical procedure worldwide and is performed by surgeons with varied training. The outcome and complication rates are largely dependent on surgeon's skill and experience, the extent of surgery, indication of surgery and number of thyroid surgeries performed at that particular centre. The objective of this study was to determine the frequency of postoperative complications after thyroid surgery in Hyderabad, Pakistan. It was a descriptive study and was carried out at 2 private hospitals including a teaching University Hospital over a period of 3 years from April 2005 to March 2008. All patients with goitre, who underwent any sort of thyroid surgery, were included in this study. Patients' bio-data including name, age sex, clinical status of thyroid, thyroid function tests, ultrasound, fine needle aspiration cytology and operative procedure, findings, post operative complications and histopathology reports were recorded. Data were analysed using SPSS 16.0. The overall postoperative complication rate was 10.7%. Postoperative hypocalcaemia was the most frequent complication observed in 3.5% of all patients followed by recurrent laryngeal nerve [RLN] injury noted in 2.8% patients. The less common complications were bleeding, seroma formation and wound infection. Majority of these complications were associated with total thyroidectomy, male gender, and in patients with age more than 30 years. The commonest post thyroidectomy complication was hypocalcaemia. Male gender, old age, and extensive thyroid surgery were associated with increased complication rate

Practice of surgeons regarding examination of pathological specimens in operating room

The debate of routine versus selective submission of specimens for histopathology makes it important to know the present practice of surgeons. The objective of this study was to determine the proportion of general surgeons examining the gall bladder and appendix specimens in operating room before submission for histopathology. This questionnaire based survey was conducted for the general surgeons working in the city of Hyderabad, Pakistan during May-June 2008. The data was entered and analysed in SPSS 11.0 software statistical program to determine the impact of designation, hospital category and experience on the responses of surgeons. Overall, 42 out of 47 qualified general surgeons working in Hyderabad, Pakistan responded the questionnaire. About 23.8% and 4.8% reported to be always examining gall bladder and appendix specimens respectively in operating room. About 66.7% and 40.5% reported to be submitting every gall bladder and appendix specimen respectively for histopathology. Lack of practice and poverty were reported as the common causes of not examining the specimen in operating room and not submitting every specimen for histopathology respectively. About 25.8% and 81.8% from public and private sector hospitals respectively reported to be submitting every appendix specimen for histopathology. About 88.2% and 52% of surgeons having experience of five years or less and experience of more than five years respectively reported to be submitting every gall bladder specimen for histopathology. There is widespread variation in the practice of general surgeons regarding operating room examination as well as submission of specimens for histopathology

diagnostic value of fine needle aspiration cytology in thyroid nodules

The purpose of this study was to determine the diagnostic value of fine needle aspiration cytology [FNAC] for thyroid nodules. Descriptive study. This study was carried out at two private hospitals including a teaching university hospital i.e. Isra University Hospital, Hyderabad over a period of three years from April 2005 to March 2008. All patients with thyroid nodule [solitary and dominant], diagnosed on the basis of history, clinical examination and radiological investigations were included in this study. FNAC was performed by standard technique before undergoing operation for thyroid nodule and then the resected specimens were submitted for histopathology. The data was analyzed to determine the sensitivity, specificity, accuracy and positive and negative predictive values of FNAC for thyroid nodules. Overall, 142 patients underwent FNAC during the three years study period. Final histopathology confirmed benign lesions in 78 out of 84 FNAC proven benign lesions while 11 out of 12 FNAC proven malignant lesions were confirmed on final histopathology. The sensitivity and specificity of FNAC were found to be 65% and 98% respectively. The diagnostic accuracy was 92.8% whereas positive and negative predictive values were 91.6% and 93% respectively. FNAC is a highly sensitive, specific and accurate procedure for the diagnosis of the thyroid nodules. It plays a useful role in planning the surgical management of thyroid nodules as it helps significantly in differentiating between benign and malignant lesions

Frequency of gall bladder carcinoma in patients undergoing surgery for cholelithiasis

To determine the frequency of gall bladder carcinoma in patients undergoing surgery for cholelithiasis at Isra University Hospital, Hyderabad, Singh- Pakistan. This was a descriptive study, conducted from April 2006 to March 2008 at Isra University Hospital Hyderabad, Pakistan. This study included 200 cases of cholelithiasis who underwent cholecystectomy at out Hospital. Patients belonged to both sexes having cholelithiasis, diagnosed on the basis of clinical grounds and supported by ultrasonography. A uniform procedure of history taking, physical examination, investigations and treatment was adopted for all the patients, and data were recorded on the pre-designed proforma. Of 200 cases that were operated for gall bladder stone disease, eight were found to have carcinoma of gall bladder i.e. frequency was 4%. The age ranged from 35 to 70 years, with mean 50[ +/- 5.3] in females and 56[ +/- 2] in males. Male to female ratio was 1:3. On ultrasound, only three [37.50%] patients with advanced disease had a pre-operative clue of carcinoma. The frequency of gall bladder carcinoma in our population seems much higher than Western populations. Females are more affected than males by this problem. Ultrasonography can miss malignant lesions; therefore every gall bladder specimen should be subjected to histopathology. While in unsuspected cases undergoing laparoscopic cholecystectomy, gentle handling of the gall bladder is critical to avoid port site implantation caused by spillage of bile

Trichobezoar: an uncommon surgical problem

Trichobezoar is an uncommon condition characterized by impaction of swallowed hair in the gastrointestinal tract. This is a case report of young psychiatric male presenting with well defined left hypochondriac mass. Upper GI endoscopy and CT scan were used to confirm the diagnosis of trichobezoar. The patient underwent exploratory laparotomy and a huge trichobezoar was removed. Along with the surgical follow up, patient also received psychiatric treatment postoperatively

Appropriate cut-off value of alvarado scores for patients undergoing appendectomy at Isra university hospital, Hyderabad

To determine the frequencies as well as the appropriate cut-off value of Alvarado scores in patients undergoing appendectomy at Isra University Hospital, Hyderabad-Sindh, Pakistan. A descriptive study. Isra University Hospital, Hyderabad, from September 2007 to September 2008. One hundred consecutive patients fulfilling the selection criteria during the above mentioned period were included in this study. After the detailed history, clinical examination and relevant investigations, the Alvarado score was calculated for each patient. After appendectomy, the relationship of operative and histopathological findings with Alvarado score as well as cut-off points for the decision of appendectomy was analyzed. The majority of patients were between the ages of 15 to 30 years with male to female ratio of 2.2:1. The commonest operative finding was acutely inflamed appendix followed by perforated appendix. Gangrenous appendix and normal looking appendix. A majority [57%] of the patients had Alvarado scores of eight or more. None of the patients having a score of four or less was operated. Normal and perforated appendices were not found in patients having Alvarado scores of eight or more and seven or less, respectively. In this study, 8%, 16%, 19%, 22%, 26% and 9% of the patients undergoing appendectomy had Alvarado scores of five, six, seven, eight, nine and ten, respectively. An Alvarado score of seven was the most appropriate cutoff value for the decision to perform appendectomy

Thyroid scintigraphy: an overused investigation

Thyroid disorders are commonly encountered in general surgical practice. The purpose of this study was to determine how closely thyroid scintigraphy was ordered according to its indications in patients with thyroid diseases and the magnitude of its impact on the management. This cross-sectional study was carried out mainly at Isra University Hospital, Hyderabad over a period of 3 years from May 2005 to April 2008. All patients presenting with thyroid swelling and undergoing any type of thyroid operation were included in the study. Special emphasis was made on the indication of thyroid scintigraphy in these patients and its impact on the treatment. Out of 140 patients, 98 had thyroid scintigraphy done. Among these only 26 patients [26.5%] had it according the indication. In remaining 72 patients, thyroid scintigraphy did not reveal any added information to help in treatment plan. Thyroid scintigraphy is an overused investigation in thyroid patients. Routine use of thyroid scintigraphy in all goiter patients should be discouraged

Etiological spectrum of obstructive Jaundice

The objective of this study was to determine the etiological spectrum of obstructive jaundice in this part of the world. This prospective study was carried out at Liaquat National Hospital, Karachi from March 1997 to February 2001 and later at Isra University Hospital, Hyderabad from January 2003 to December 2006. Sixty five patients with obstructive jaundice were included in this study. The data was collected with respect to patient's identity, age, gender and cause of the obstructive jaundice. Fifty seven percent of patient had malignant obstructive jaundice and carcinoma of head of pancreas being the leading cause of malignant obstructive jaundice. Forty three percent patients had benign causes of obstructive jaundice, choledocholithiasis being the most common benign cause. Choledocholithiasis and malignancy are the two major causes of obstructive jaundice

Superiority of laparoscopic appendectomy over open appendectomy: the hyderabad experience

To compare the out come of laparoscopic and open appendicectomies in terms of operative time, analgesic requirement, postoperative complications, hospital stay, return to normal activity and condition of scar. This prospective study was carried out in Department of Surgery, Liaquat University Hospital Hyderabad/ Jamshoro from September 1997 to August 2000. One hundred consecutive patients of age ranging from 15-45 years with features suggestive of acute appendicitis were equally divided into laparoscopic appendectomy [LA] and open appendectomy [OA] groups, after taking informed consent. LA was done with the help of three trocar/cannulae creating pneumoperitoneum with CO2 whereas OA was performed by Lanz incision. The data were analyzed by Student t-test and Chi square tests using SPSS version 10. The operating times in OA and LA were 20-70 minutes [mean 30] and 25-95 minutes [mean 55] respectively. Increased doses of analgesics, antibiotics and antiemetics were required in OA, as compared to LA. The mean postoperative hospital stay in LA group was 1.4 days [range 1-3 days] whereas it was in OA group, it was 3.5 days [range 2-6 days]. 2 LA is safe and has major benefits like less postoperative pain, decreased wound infection, early hospital discharged, early return to work and a better cosmetic scar than OA

Unusual variant of Cantrell's pentalogy?

A 12-hour-old male infant presented with prolapsed abdominal content through a defect on left side of chest wall with respiratory distress. A thorough clinical examination suggested absence of ectopia cordis, abdominal wall defect, and any bony anomaly. The child expired after 6 hours of admission because of respiratory distress and electrolyte imbalance. Is congenital defect of chest wall associated with diaphragmatic hernia without ectopia cordis and omphalocele, an unusual variant of Cantrell's pentalogy?