Ultrasound-guided quadratus lumborum block versus ilioinguinal-iliohypogastric nerve block with wound infiltration for postoperative analgesia in unilateral inguinal surgeries: A randomised controlled trial.

Background and Aims: Ultrasound (US)-guided quadratus lumborum (QL) block is an abdominal field block that has high efficacy in providing postoperative analgesia for abdominal surgeries. This study was undertaken to compare the US-guided QL block with ilioinguinal-iliohypogastric (IIIH) nerve block and local wound infiltration in unilateral inguinal surgeries, in terms of analgesia and overall patient satisfaction. Methods: This randomised controlled trial was conducted in two groups of thirty each. After the completion of surgery under spinal anaesthesia, patients in Group QL received 20 ml of inj. ropivacaine 0.5% while patients in Group IL received 10 ml of inj. ropivacaine 0.5% at the ilioinguinal-iliohypogastric nerve site and 10 ml of inj. ropivacaine 0.5% that was locally infiltrated at the surgical site. Duration of analgesia, Visual Analogue Scale (VAS) score, total requirement of analgesic dosage in the first 24 hours, and patient satisfaction score were compared in both the groups. Statistical analysis was performed using unpaired student's t test and Chi-squared test with IBM SPSS Statistics version 21 software. Results: Duration of analgesia was significantly higher in Group QL (544.83 ± 60.22 min) when compared with Group IL (350.67 ± 67.97 min; P < 0.0001). VAS scores and analgesic requirements were also lower in Group QL. The patient satisfaction score was significantly higher in Group QL (3.93 ± 0.91) when compared to Group IL (3.4 ± 1.0; P < 0.05). Conclusion: US-guided QL block significantly prolongs the duration and quality of postoperative analgesia, thereby reducing analgesic consumption and increasing overall patient satisfaction.

Comparison of Different Ultrasound Parameters for Airway Assessment in Patients Undergoing Surgery under General Anaesthesia.

AIMS: The aim of this study was to evaluate and correlate ultrasound measurement of airway parameters with the Cormack- Lehane (CL) grading observed under direct laryngoscopy for prediction of difficult airway. METHODS: This prospective, observational study was conducted in a tertiary care institute. Ninety-six patients were scheduled for elective surgery under general anaesthesia and tracheal intubation. They were categorised as having easy (CL grades 1, 2a, and 2b) or difficult (CL grades 3a, 3b, and 4) laryngoscopy. The sonographically measured airway parameters included anterior neck soft tissue thickness at vocal cord level (ANS-VC), hyomental distance ratio (HMDr), and tongue volume (TV). These parameters were compared and correlated with the CL grading. The statistical analysis was done using SPSS version 21.0. RESULTS: Difficult laryngoscopy was observed in 17.7% patients. Significant difference was noted in ANS-VC 0.28 6 0.09; 0.39 6 0.12, (P < .0001) and HMDr, 1.2 6 0.09; 1.15 6 0.13, (P » .006) for easy and difficult laryngoscopy, respectively. ANS-VC had a sensitivity of 78.9% and specificity of 71.1% (AUC-0.816) followed by HMDr (AUC-0.713) and TV (AUC-0.608). Combined ultrasound parameters had significantly higher AUC value (0.867). CONCLUSIONS: ANS-VC was the most significant parameter with a value of >0.29 cm being a sensitive predictor of difficult intubation. Combined sonographic parameters (ANS-VC, HMDr, and TV) were better predictors of difficult intubation.

A feasibility study to assess vallecula and pyriform sinus using protocol-based ultrasonic evaluation of floor of mouth and upper airway.

PURPOSE: The current study aimed to systematically evaluate the sonoanatomy of floor of the mouth and upper airway using protocol-based ultrasonography (USG); and to assess the feasibility of imaging the valleculae and pyriform fossae. MATERIALS AND METHODS: An institutional prospective observational study was planned on fifty volunteers of all ages and both sexes, attending outpatient department for nonairway-related diseases. Protocol for ultrasonographic systemic evaluation was designed before starting the trial. All the patients were positioned supine with neck extended (sniffing position), seven steps of ultrasonographic protocol were followed and visualization of structures denoted in each step was documented. Furthermore, time taken to complete each scan was noted. RESULTS: The USG was completed, and checklist successfully followed in all cases. Floor of mouth structures was easy to evaluate and visualized with ease in all the cases. Epiglottis was visualized in 100% cases in transverse plane. Valleculae and pyriform fossae were identified in 82% and 90% of the cases, respectively, and they appeared either as paired air-filled round structures or air-lined linear structures. Complete visualization of vocal cords was seen in 78% females and 63% males. The average time taken to complete the protocol-based study was 10.4 ± 1.4 min. CONCLUSIONS: Application of protocol-based USG for upper airway can allow the examination of structures from tongue to thyroid cartilage in a thorough, convenient, and timely manner. The air filled/lined structures such as valleculae, pyriform fossae, and vocal cords can be visualized in majority of the cases.

Correlation of quality of life scores to clinical outcome of lumbar epidural steroids in chronic low back pain.

CONTEXT AND AIM: The assessment of severity of low back pain includes subjective questionnaires to quantify the impact on routine life. The objective of current study was to correlate various quality of life (QOL) scores to the clinical outcome measured as improvement in Visual Analog Score (VAS) after interventional treatment. SUBJECTS AND METHODS: Fifty-one consecutive chronic low backache patients were assessed for pain intensity using VAS, revised Oswestry Disability Index (ODI), Quebec's, Roland-Morris disability questionnaire (RMDQ), and depression score at presentation. All subjects received interventional therapy complemented with physiotherapy; changes in scores were evaluated at 2 weekly intervals till 12 weeks. TYPE OF STUDY: Prospective, observational, cohort study. RESULTS: All scores depicted highly significant statistical improvement over baseline scores (P < 0.001). The Pearson correlation of VAS with rest of the scores showed that all variables correlate well with VAS at various time periods till 3 months. However, the best outcome predictor for VAS in QOL scores was Oswestry score as well as depression score which had an additive predictive effect. Among the QOL scores best intercorrelation was found with ODI and RMDQ scores at baseline as well as at all treatment follow-ups. INTERPRETATION AND CONCLUSION: ODI and depression score closely parallel trends of reduction in VAS indicating that these scores may be the best outcome predictor after interventional treatment of pain. Among QOL scores ODI and RMDQ evaluated in the current study record comparable degree of physical incapacity; the exception is Quebec's score.

Effect of the perioperative infusion of dexmedetomidine on chronic pain after breast surgery.

BACKGROUND: This prospective double-blind trial was undertaken to analyze the role of perioperatively administered dexmedetomidine on the occurrence of chronic pain in cases undergoing surgery for breast cancer. SUBJECTS AND METHODS: Eighty-six cases were randomly assigned to two groups to receive either dexmedetomidine (2 µg/ml) in group D or saline in group C, in a loading dose of 0.5 ml/kg, intravenous (IV), 30 min prior to induction, followed by a continuous infusion of 0.25 ml/kg/h IV till the completion of surgery, and then the dose tapered to 0.1 ml/kg/h for up to 24 h. The standardized questionnaires that measured chronic pain (Brief Pain Inventory, BPI; Short Form McGill Pain Questionnaire, SF-MPQ2) and quality of life (Quality of Life Scale, QOLS) were gathered after 3 months of surgery as a primary outcome. Pain (verbal numerical score, VNS), sedation scores (Ramsay scoring), and analgesic requirements were also assessed for 72 h postoperatively. RESULTS: In total, 84 cases (n=42) were analyzed for acute pain and 69 (34 in group D and 35 in group C) for chronic pain. The consumption of isoflurane/fentanyl intra-operatively and paracetamol postoperatively was significantly lower in Group D. The sedation scores were non-significant between the groups. The VNS at rest and after movement was significantly lower in group D at corresponding times (except at 60 min) throughout the assessment period. The BPI and SF-MPQ2 scores were significantly lower in group D in most of the factors. The QOLS score was significantly better in group D in all items except for relationships, friends, and learning. CONCLUSION: The perioperative infusion of dexmedetomidine has a pivotal role in attenuating the incidence and severity of chronic pain and improving the quality of life in cases undergoing breast cancer surgery.

Comparison of three different formulations of local anaesthetics for cervical epidural anaesthesia during thyroid surgery.

BACKGROUND: To compare the efficacy and safety of local anaesthetics under cervical epidural anaesthesia (CEA) using lignocaine (1%), bupivacaine (0.25%) and ropivacaine (0.5%) for thyroid surgery. METHODS: In a prospective, randomized fashion, 81 patients were selected for thyroid surgery under CEA. They were assigned to one of three groups: Group L, B and R to receive 10 mL of 1% lignocaine, 0.25% bupivacaine and 0.5% ropivacaine, respectively. We compared their efficacy in terms of pulmonary and haemodynamic parameters, blockade quality and complications. RESULTS: Of the total, 74 patients completed the study successfully. Sensory block attained the median dermatomal range of C2-T4/T5 in all the groups. Motor block was more pronounced in the ropivacaine group. Cardiorespiratory parameters decreased significantly in all the groups; however, none of the patients had any major complications except for bradycardia in two patients. Among the measured variables, the decrease in heart rate and peak expiratory force was more in the lignocaine group while forced vital capacity and forced expiratory volume at 1 sec declined to a greater extent in the ropivacaine group. The lignocaine group required significantly more epidural top-ups compared with the other two groups. CONCLUSION: We conclude that cervical epidural route can be safely used for surgery on thyroid gland in patients with normal cardiorespiratory reserve, using either of local anaesthetics chosen for our study. Under the selected dose and concentrations, the decrease in cardiorespiratory parameters was lesser with bupivacaine.

Comparison of low doses of intrathecal bupivacaine in combined spinal epidural anaesthesia with epidural volume extension for caesarean delivery.

AIMS AND OBJECTIVES: This study aims to compare relative efficacy of three different doses of intrathecal bupivacaine in combined spinal epidural anaesthesia (CSEA) for caesarean delivery. MATERIALS AND METHODS: In a double blinded manner, 204 cases were randomized into three groups: I, II, and III to receive a dose of 4, 5.5, and 7 mg of hyperbaric bupivacaine with a fixed dose of 25 µg fentanyl intrathecally, and Dextran 40 w/v 10 mL given for epidural volume extension (EVE), in CSEA. Our primary outcome was the number of effective doses. The block characteristics and side effects were also monitored. RESULTS: Out of 198 patients completing the study, 53, 63, and 65 in group I, II and III had effective doses. Mean Pi (probability of an effective dose) in group I, II, and III, was 0.81, 0.95, and 0.97, respectively. The Pb (superiority of one group over the other) of group II and III was higher than group I. The maximal sensory block height in group II and III (T2) was higher than group I (T3), with a shorter time required to achieve the same. Group I and II exhibited lesser motor blockade, lesser hypotension with early recovery as compared to group III. No significant adverse effects were observed between the groups. CONCLUSION: The intermediate dose of bupivacaine (5.5 mg) provided safe and effective anaesthesia for caesarean delivery with an additional advantage of lesser episodes of hypotension and partial motor blockade in CSEA.

Pregabalin premedication - A new treatment option for hemodynamic stability during general anesthesia: A prospective study.

BACKGROUND: Hemodynamic responses of laryngoscopy, intubation, and pain are powerful noxious stimulus which should be attenuated by the appropriate premedication, smooth induction, and rapid intubation. CONTEXT: The oral pregabalin may attenuate the hemodynamic pressor response with intraoperative hemodynamic stability. AIMS: The present study was designed to evaluate the clinical efficacy and safety of oral pregabalin for hemodynamic stability. SETTINGS AND DESIGN: This is a prospective blind randomized controlled cohort observation study. MATERIALS AND METHODS: The 80 adult consented patients of ASA grade I and II of either gender aged 24-54 years who met the inclusion criteria were randomized to receive oral pregabalin 150 mg or placebo capsule, given 60-75 min before surgery. Patients were premedicated with metoclopramide (10 mg), glycopyrrolate (0.2 mg), and fentanyl (1 µg/kg). Anesthesia was induced with propofol and rocuronium and maintained with isoflurane, nitrous oxide, and oxygen. Both groups were assessed for preoperative sedation and changes in heart rate and mean arterial blood pressure before and after the induction and 1, 3, 5, and 10 min after laryngoscopy and intubation, then at 5 min intervals till end of surgery along with postoperative complications. STATISTICAL ANALYSIS: The hemodynamic variables were analyzed by using analysis of variance (ANOVA), Student's t test, and chi square test as appropriate. RESULTS: Preoperative sedation was higher with pregabalin with no significant change in heart rate. The mean arterial pressure was attenuated with oral pregabalin to statistically significant value (P<0.007). The requirement of analgesic drug was reduced with no postoperative respiratory depression, nausea, or vomiting and hemodynamic parameters remained stabilized perioperatively. CONCLUSIONS: Oral pregabalin premedication effectively leads to sedation and analgesia with successful attenuation of the adverse and deleterious hemodynamic pressor response.

Control of shivering with clonidine, butorphanol, and tramadol under spinal anesthesia: a comparative study.

INTRODUCTION: The present study was designed to evaluate the efficacy of clonidine, butorphanol, and tramadol in control of shivering under spinal anesthesia, and to compare their side effects. METHODS: This randomized, prospective study was conducted in 90 patients who developed shivering under spinal anesthesia during various abdominal or orthopedic surgery procedures. On shivering, patients were randomly allocated to receive an intravenous, 1 mL bolus dose of 50 mg tramadol, or 1 mg butorphanol, or 150 µg clonidine, in a double blinded manner. Control of shivering, time taken for cessation, recurrence, hemodynamic changes, axillary temperatures, and side effects were noted and compared for all 3 groups. Collected data were analyzed using appropriate statistical tests. RESULTS: Butorphanol and tramadol were more effective than clonidine in suppressing shivering. Butorphanol, tramadol, and clonidine completely controlled rigors in 83%, 73%, and 53% of cases, respectively, and incompletely suppressed rigors in 16%, 26%, and 46% of cases, respectively. Time taken to terminate rigors was significantly higher for clonidine (3.3 ± 0.9 minutes) than for butorphanol and tramadol (2.1 ± 1.0 minutes and 1.8 ± 0.5 minutes; P < 0.001). CONCLUSION: Butorphanol had an edge over tramadol in controlling shivering with lower chances of recurrence, though both were superior to clonidine for this purpose with an early onset of action. We conclude that both these opioids control rigors better than α-2 agonists.

Smile Train project: a blessing for population of lower socio-economic status.

The Smile Train Project is an international charity dedicated to poor children with cleft lip and cleft palate abnormalities with an aim to restore normal or near normal anatomy, function, satisfactory facial appearance and speech. A review was done among 241 patients of cleft lip and palate anomaly, admitted at Subharti Medical College, Meerut, for cheiloplasty and palatoplasty between May 2006 and December 2008 in collaboration with the department of maxillofacial surgery and its incidence in relation to age and sex distribution. Ideally infants with cleft lip alone should be repaired within the first six months of age and cleft palate should be repaired before development of speech ie, at the age of 2 years. But in this study only 25% of patients who underwent corrective surgery were up to 2 years of age and more than 47% cases were operated between the ages of 2 and 10 years. Sixty-six cases (27%) were operated between ages of 10 and 35 years. It may be due to ignorance, poverty or unawareness about the fact that cleft anomaly can be corrected by surgery. Without repair, these children would have suffered from facial disfigurement, feeding problems, social isolation and abnormal speech. Smile Train Project along with motivation of health workers of this institute has made their smiles more socially acceptable.

Anesthetic management for Smile Train a blessing for population of low socioeconomic status: A prospective study.

BACKGROUND: The Smile Train is an international charity with an aim to restore satisfactory facial appearance and speech for poor children with cleft abnormalities who would not otherwise be helped. A total of 241 children of cleft lip and palate anomaly, scheduled for surgery under general anesthesia, were studied. Cleft abnormality requires early surgery. Ideally cleft lip in infants should be repaired within the first 6 months of age; and cleft palate, before development of speech, i.e., at the age of 2 years. But in our study, only 27% of children underwent corrective surgery by ideal age of 2 years, which may be due to ignorance, poverty or unawareness about the fact that cleft anomaly can be corrected by surgery. CONTEXT: Smile Train provides care for poor children with clefts in developing countries. The guidelines were designed to promote safe general anesthesia for cheiloplasty and palatoplasty. AIMS: Smile Train promotes free surgery for cleft abnormalities to restore satisfactory facial appearance and speech. SETTINGS AND DESIGN: This was a randomized prospective cohort observational study. MATERIALS AND METHODS: A total of 241 consenting patients of American Society of Anesthesiologt (ASA) I and II aged 6 months to 20 years of either sex, scheduled for elective cheiloplasty and palatoplasty, were studied. Children suffering from anemia, fever, upper respiratory tract infections or any associated congenital anomalies were excluded. Approved guidelines of the Smile Train Medical Advisory Board were observed for general anesthesia and surgery. STATISTICAL ANALYSIS: The Student t test was used. RESULTS: The infants were anemic and undernourished, and two thirds of the children were male. Only 27% of the children presented for surgery by the ideal age of 2 years. CONCLUSIONS: Pediatric anesthesia carries a high risk due to congenital anomaly and shared airway, venous access and resuscitation; however, cleft abnormality requires surgery at an early age to make the smiles of affected children more socially acceptable.

Anaesthetic management of an epileptic pregnant woman for trauma surgery--a case report.

A young epileptic woman with twin pregnancy (IUD) was posted for orthopaedic correction under general anaesthesia on assisted ventilation with laryngeal mask airway (LMA). The present article focuses on anaesthetic concerns in pre-operative preparation and management of such patients.