Comparison of Lumbar Transforaminal Epidural Dexamethasone and Triamcinolone for Lumbar Radiculopathy

Epidural blockade is becoming one of the most useful and versatile procedures in modern anaesthesiology. What is unique is its application to clinical practice, as it can be placed virtually at any spinal level of vertebral column that allows considerable flexibility. Epidural steroid injections through lumbar transforaminal route to treat pain in lower back where radiculopathy is also associated with, are used widely. It has been reported that these procedures in lumber spine are effective clinically for improved physical function in patients as well as relief of pain of short- and long-term duration. We wanted to determine as to whether there is a difference in the efficacy between nonparticulate (e.g. dexamethasone phosphate) and particulate (e.g. triamcinolone acetate) steroids in Lumbar Epidural via transforaminal approach for acute radicular pain in lumber region and adverse effects of the drugs if any. METHODS66 patients, 33 in each group, with dexamethasone phosphate 8 mg or triamcinolone acetate 40 mg for lumbar transforaminal approach epidural steroid injection, were randomized. Observation was done through visual analog scale, short McGill pain questionnaire, revised Oswestry Disability Index before intervention and a month later. RESULTSA difference which was significant statistically in the visual analog score (2.85 ± 0.83 in group T, 5.76 ± 0.75 in group Dx), McGill Pain Questionnaire (3.73 ± 1.15 in group T, 6.55 ± 0.51 in group Dx) and Oswestry Disability Index (18.67 ± 7.13 in group T, 35.83 ± 5.10 in group Dx ) was found in both but was more in triamcinolone group. CONCLUSIONSEfficacy is more in particulate (triamcinolone) than non-particulate (dexamethasone) in epidural injection through lumbar transforaminal with no drug related complication, performed for radiculopathy in lumbar region.

Giant Neck Mass in a Patient with Mallampati Classification 3- Anaesthetic Management.

The American Society of Anesthesiologists (ASA) task force defined a difficult airway as “a clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both”.[1] The task force further noted that the “difficult airway" represented a complex interaction between patient factors, the clinical setting, and the skills and preferences of the practitioner. Lipomas are slow-growing benign soft-tissue tumours which are typically asymptomatic. Giant lipomas in the cervical region of neck are rare. A lipoma is considered to be of excessive size when it exceeds 10 cm in length in any dimension or weighs over 1000 g. During induction of anaesthesia, a huge mass on the back of neck which does not allow the patient to lie supine is a risk factor for difficult airway.[2,3,4]Proper positioning is pertinent for induction of anaesthesia, securing the airway and surgical accessibility. In patients with anticipated difficult airway, fiberoptic intubation under spontaneous ventilation has been considered an effective and safe choice, taking into account that laryngoscopic intubation may worsen any difficult airway scenario.[5] We report a case of huge lipoma over the back of neck that limits neck movements in a patient having mouth opening of one finger due to chronic tobacco chewing.A mass on upper back which limits positioning of the patient supine for induction of anaesthesia is a challenge for anaesthesiologists for the management of airway. Complications due to airway manipulation are one of the commonest causes for anaesthesia related morbidities and mortalities. We report the anaesthetic management of a 55 year old male patient, having mouth opening of one finger due to chronic tobacco chewing, protruding teeth in upper jaw and missing teeth in lower jaw scheduled for resection of a giant mass (huge lipoma), over the upper back that restricted flexion and extension movement of the neck. We selected awake fibreoptic bronchoscopy assisted endotracheal intubation as a safe approach in this difficult airway scenario.

The Effect of Intrathecal Magnesium Sulphate on Bupivacaine-Fentanyl Subarachnoid Block for Infraumbilical Surgeries

Local anaesthetics with additives in a wide range, affect the versatility of spinal anaesthesia. Amongst a diverse class of drugs, phenylpiperidine derivative fentanyl, NMDA receptor blocker magnesium have been added as adjuvants to amide local anaesthetic hyperbaric bupivacaine for spinal anaesthesia in an attempt to prolong analgesia.METHODS70 patients of either gender were selected randomly and were divided into two groups of 35 each. Administered intrathecally in Group S (control) 12.5 mg of hyperbaric bupivacaine, 25 mcg of fentanyl, 1 mL of normal saline and in Group M (study) 12.5 mg of hyperbaric bupivacaine, 25 mcg of fentanyl, 50 mg of magnesium sulphate.RESULTSInsignificant haemodynamic variability was observed following the addition of magnesium to the spinal block agent. Onset (min.) of sensory block was 7.8 ± 1.2 in group M, 5.3 ± 1.0 in group S which was statistically significant with p-value of < 0.00001. Onset (min.) of motor block was 13.2 ± 1.5 in group M, 10.4 ± 2.1 in group S which was statistically significant (p- value < 0.00001). Duration of analgesia (min) was 290.3 ± 9.5 in group M and 261.3 ± 12.2 in group S which was statistically significant with p- value <0.00001. The recovery from the motor block (min) was 242.5 ± 9.4 in group M, 236.5 ± 5.5 in group S, the difference was statistically significant (p- value of 0.002). At 8th hr mean of VAS was 3.65 ± 0.90 in Group M, 4.62 ± 0.68 in Group S, statistically significant, with p-value of <0.00001CONCLUSIONSMagnesium added to hyperbaric bupivacaine with fentanyl for spinal anaesthesia significantly prolongs the onset and duration of analgesia, onset and recovery from motor block, less score of VAS, without significant haemodynamic variations and adverse effects.

Evaluation of the merits of two drugs-dexmedetomidine and ketamine for day care hysteroscopic procedures

Background: The aim was to compare the hemodynamic changes intra operatively and to ascertain the superior efficacy of the study drugs Dexmedetomidine, a highly selective alpha-2-adrenoceptor agonist having sympatholytic, dose dependent sedation, analgesic properties, amnestic effect without respiratory depression and Ketamine, a n-methyl-d-aspartate receptor antagonist, a dissociative sedative hypnotic with potent analgesic properties and marked sympathomimetic effects, have been taken for day care (ambulatory) hysteroscopic procedures. The objectives are to evaluate the requirement of rescue sedative and /or analgesic during the procedure and any complication of the drugs per-operatively.Methods: About 25 patients in each group in the range of age 20 to 55 years, weight 40-60 kg, height 145-155 cm, ASA I and II were injected with dexmedetomidine (D) 100 µg IV or Ketamine (K) 75 mg IV both over 10 mins at the onset of the procedure. Maintenance of anaesthesia had been done on mask ventilation with 30% oxygen and 70% nitrous oxide.Results: The demographic data was statistically insignificant. The haemodynamics were stable in the group D, not in group K, ‘p’ value <0.0001. The request for rescue sedation propofol and rescue analgesic fentanyl and the number of top up doses were higher in the group K, p’ value <0.01, statistically highly significant. Group K had suffered more per-operative complications.Conclusions: Dexmedetomidine for day care hysteroscopic procedures can be the anaesthetic drug of choice.

Conscious Sedation: An Observation.

Conscious sedation is a drug-induced depression of consciousness while the patient remains awake to respond to the verbal commands. Certain diagnostic and therapeutic procedures can be carried out under local anesthesia with sedation and analgesia without any requirement for intervention of maintenance of cardiorespiratory function. The hemodynamic status and the level of consciousness needed for the procedures remain continuously under the vigilance and control of a qualified anesthesiologist. An essential component of conscious sedation or monitored anesthesia care, which is a planned procedure, is the assessment and management of a patient’s actual or anticipated physiological derangements or medical problems that may occur during the diagnostic or therapeutic procedure carried out under sedation.

Yoga: A Therapeutic Adjuvant.

Illness occurs when the total balance of perfect health is deranged. Yoga with asanas relax and tone the muscles as well as massage the internal organs. Thus, inner harmony is restored and health on all levels improves. The aim of Yoga is to maintain a balance between the psychopathological and spiritual aspects. Yoga, fundamentally different from conventional medical treatment, is considered a therapeutic adjuvant.