Analgesic efficacy of surgeon-assisted transverse abdominis plane block in patients undergoing open cholecystectomy.

Background: Unavailability of ultrasound and unpredictable success with traditional blind technique makes Transversus Abdominis Plane Block under-utilized in developing country like India. Aims & Objective: The present study was designed to evaluate the analgesic efficacy of Surgeon-assisted Transversus Abdominis Plane Block as an adjuvant to routine analgesic in reducing pain score during first 12 hours postoperatively in patients undergoing open cholecystectomy. Material and Methods: This was randomized, double-blinded, controlled, clinical trial carried out in tertiary care, teaching hospital. All the patients received a routine general anaesthesia with standard monitoring. Group A received routine analgesic which included Diclofenac sodium 75 mg intravenously (IV) at 8 hourly and group B received routine analgesic & Transversus Abdominis Plane Block with 15 ml of bupivacaine 0.25% at the end of surgery. Visual analogue score for pain, incidence of post-operative nausea and vomiting and demand of rescue opioid (Tramadol 2 mg/kg IV) in post-operative period were assessed every 2 hourly up to 12 hours after the surgery by an investigator blinded to group allocation. Results: Transversus Abdominis Plane block reduced visual analogue scale for pain on emergence and at all postoperative time points up to 12 hours (p < 0.0009). The incidence of post-operative nausea and vomiting, and demand of rescue opioid in the first 12 postoperative hours were also reduced (p < 0.0001). There were no complications attributable to the block. Conclusion: Transversus Abdominis Plane Block is effective as an adjuvant to routine analgesic to reduce pain after open cholecystectomy and reduces post-operative opioid demand and nausea & vomiting.

Neutral versus 45 degree rotated position of head for internal jugular vein cannulation: A comparative study based on ultrasonography.

Background: Most of the methods do not specify its optimal degree of head rotation during central venous catheterization. Aims & Objective: To compare neutral versus 45 degree rotated position of head for internal jugular vein (IJV) cannulation based on ultrasonography. Material and Methods: This prospective, randomized study was conducted in a teaching and tertiary care hospital. Randomly selected 100 healthy volunteers were placed supine with 15º trendelenberg position. Head of the volunteer was kept neutral in group N (100 volunteers) and 45º rotated in group R (100 volunteers). 7.5 M Hz linear array probe of a portable ultrasound was placed perpendicular to the apex of triangle formed by two heads of sternocleidomastoid muscle and clavicle. We simulated a line as a needle insertion on ultrasound screen passing the mid-point of the IJV. A “hit” was defined as the intersection of the inner lumen of carotid artery (CA) by simulated line. The observations were recorded for both sides of neck for each group. Student’s t test was applied for quantitative data and Fisher exact test for qualitative data. P value < 0.05 was taken as significant. Results: The frequency of ‘Hit’ was less in group N than R (right side: 5% versus 15%, p=0.0317; left side: 15% versus 28% p=0.0381). Total frequency of ‘Hit’ was less in right side than left side for both groups (p<0.05). The diameter of IJV and CA were comparable in both groups for right and left side of neck (p>0.05). The distance of IJV from skin was more in group N than R (right side: 10.29±1.88 versus 9.75±1.88, p=0.0436; left side: 10.75±1.87 versus 10.21±1.86, p=0.0416). Conclusion: A neutral position was safer than 45 º neck rotation during IJV cannulation with regard to CA puncture.

Anatomical variations of the internal jugular vein in relation to carotid artery : an ultrasound study.

Background: In developing country like India, central venous catheter is still inserted using anatomical landmark guidance with success rate up to 97.6% and complications up to 15%. Aims & Objective: This study was aimed to determine the anatomical variations of the internal jugular vein (IJV) in relation with carotid artery (CA) with the help of 2-D ultrasound. Material and Methods: This prospective randomized study was conducted in a teaching and tertiary care hospital on 100 young healthy volunteers of either sex, aged 20 years to 40 years. Each volunteer was placed supine with 15˚ down trendlenberg position with 45˚ neck rotation on contra-lateral side. Linear array probe with 7.5 M Hz of “Sonosite Micromaxx” ultrasound machine was placed perpendicular to the apex of the triangle formed by two heads of sternocleidomastoid muscle and clavicle. Vessels were visualized in transverse section in 2-D ultrasound. Exact location of IJV was identified in relation to the CA on ultrasound and recorded as lateral, antero-lateral, anterior, medial, and posterior. The diameter of IJV and CA, distance from skin to IJV were recorded on both sides of neck for each volunteer. Anterior position of IJV in relation to CA was defined as dangerous position. Small sized IJV was defined as diameter ≤7 mm. Data were analyzed using Graphpad prism software version 5.1. P value < 0.05 was taken as significant. Results: The mean diameter of IJV was 13.23 (2.52) mm in right and 10.25(2.29) mm in left side of neck (p=0.0001). Small sized IJV was in 1% in right and 8% in left side (p=0.0349). 15% and 28% of volunteers had dangerous position of IJV in relation to CA on right and left side of neck respectively (p=0.0381). Conclusion: Significant number of healthy young volunteers had anatomical variations in terms of size and position of IJV (left side > right side) in relation of CA by ultrasound screening. Thus, anatomical landmarks are not sufficient, alternative measures like ultrasound scanning should be implemented prior to catheterization to identify the individual with potentially difficult catheterization.

Experience with Kangaroo mother care in a neonatal intensive care unit (NICU) in Chandigarh, India.

OBJECTIVE: To study the feasibility and acceptability of Kangaroo mother care (KMC) on the low birth weight infants (LBWI) in the neonatal intensive care unit (NICU) by the mothers, family members and health care workers (HCW) and to observe its effect on the vital parameters of the babies. METHOD: A observation in the NICU. RESULTS: A total of 135 babies (74 boys and 61 girls) who completed minimum of 4 hrs of KMC/day, were included. The mean birth weight and gestation were 1460 gm and 30 week respectively. 47% babies started KMC within first week of age. Mean duration of KMC was 7 days (3-48) days. The O(2) saturation improved by 2-3%, temperature ( degrees C) rose from 36.75 +/- 0.19 to 37.23 +/- 0.25, respiration stabilized (p<0.05 for all) and heart rate dropped by 3-5 beats. No episodes of hypothermia or apnea were observed during KMC. KMC was accepted by 96 % mothers, 82% fathers and 84% other family members. 94% HCW considered it to be safe and conservative method of care of LBWI. Benefits of KMC on the babies' behavior and on maternal confidence and lactation were reported by 57%, 94% and 80% respectively. A decline in use of heating devices in the NICU was reported by 85% and 79% said it did not increase their work load. CONCLUSION: KMC was found to be safe, effective and feasible method of care of LBWI even in the NICU settings. Positive attitudes were observed in mothers, families and HCW.