Music as an aid to Allay Anxiety in Patients Undergoing Orthopedic Surgeries under Spinal Anesthesia.

Introduction: Patients undergoing surgery are anxious owing to the surgery, anesthesia, and unfamiliar environment of the operation theater. This anxiety can hamper the health and recovery of the patients. Among various nonpharmacologic modalities available, music can be used as a coping strategy to change uncomfortable conditions to the pleasant ones. Aims: To evaluate the role of music on perioperative anxiety, hemodynamic parameters, and patient satisfaction in patients undergoing orthopedic surgeries under spinal anesthesia. Settings and design: Tertiary care hospital, randomized control trial. Materials and methods: : The study was conducted after approval by Hospital Ethical Committee on 70 adult patients of either gender scheduled to undergo lower limb surgeries under spinal anesthesia. In group M (n = 35), patients listened to standard relaxation music, and in group C (n = 35), patients listened to standard operation theater noise tape through noise canceling headphones. The intraoperative hemodynamic parameters were recorded. Perioperative anxiety was assessed using visual analog scale for anxiety. Sedation score was observed using observer's assessment of alertness/sedation scale. Patient's satisfaction was also assessed in both the groups. Statistical analysis: Student t test, Chi-squared test, and paired sample t test. Results: : In group M, heart rate was lower when compared with group C. The difference was statistically significant at 10 minutes of assessment (P = 0.003) and statistically highly significant (P < 0.001) for rest of the time period. Statistically significant lower respiratory rate was there in group M when compared with group C (P = 0.05). Patients were more satisfied in the music group when compared with control group. Conclusion: The potential of music therapy can be used to allay patient anxiety, stabilize hemodynamics, and improve patient satisfaction.

Outcome Analysis of En bloc Resection and Reconstruction by Non-vascularized Proximal Fibular Autograft in Giant Cell Tumor of Distal Radius supplemented with Brachytherapy.

Introduction: Giant cell tumors of the bone are aggressive and potentially malignant lesions. Juxtaarticular giant cell tumors of the lower end radius are common and is a challenge for reconstruction after tumor excision. Several reconstructive procedures like vascularized and non-vascularized fibular graft, osteoarticular allograft, ceramic prosthesis, and megapros thesis are in use for substitution of the defect in the distal radius following resection. Here, we have analyzed the results of aggressive benign Giant cell tumor of the distal radius treated by en bloc excision and reconstruction using autogenous non-vascularized fibular graft along with brachytherapy. Material and Methods: Eleven patients with either Campanacci Grade II or III histologically proven giant cell tumors of lower end radius were treated with en bloc excision and reconstruction with ipsilateral non-vascularized proximal fibular autograft. Host graft junction was fixed with low contact dynamic compression plate (LC-DCP) in all cases. Fixation of the head of the fibula with carpal bones and distal end of the ulna, if not resected, using K-wires at graft host junction was done. Brachytherapy was given in all 11 cases. Routine radiographs and clinical assessments regarding pain, instability, recurrence, hand grip strength, and functional status were done using Mayo modified wrist score at regular intervals. Result: The follow-up ranged from 12 to 15 months. At last follow-up, the average combined range of motion was 76.1%. The average union time was 19 weeks. Out of 11 patients, two patients had good results, five patients had fair results, and four patient had poor results. There was no case of graft fracture, metastasis, death, local recurrence, or significant donor site morbidity. Conclusion: En bloc resection of giant cell tumors of the lower end radius is a widely accepted method. Reconstruction with non-vascularized fibular graft and internal fixation with LC-DCP along with brachytherapy minimizes the problem and gives satisfactory functional results with no recurrence.

Comparison of Intubation Success Rate using Airtraq Laryngoscope and Intubating Laryngeal Mask Airway in Novice Users with Prior Airway Management Experience: A Prospective Randomised Study.

Background and Aims: Securing the airway without morbidity is of prime importance. The difficult airway cart should have some advanced airway aids if not all. In this study we evaluated Airtraq laryngoscope and Intubating Laryngeal Mask Airway (ILMA) as intubating devices in novice users who were well accomplished in intubation using direct laryngoscope with Macintosh blade. Both the devices were used because of relatively lesser cost, portability and all in one compact design not requiring any setup. Methods: 60 consenting American Society of Anaesthesiology (ASA) Grade I and II patients, weighing 50 to 70 were randomly assigned to be intubated by Airtraq or ILMA. Primary Aim was to compare success rate and intubation time. Comparison of ease of intubation and postoperative pharyngeal morbidity were the secondary end points. Results: Success rate of intubation was higher in ILMA group (100%) than Airtraq (80%) [P = 0.0237]. However, in successful intubations the time for intubation was significantly less with Airtraq (Group A = 45.37 ± 27.55, Group I = 77.6 ± 31.85; P = 0.0003). No significant difference was noted in ease of intubation, number of optimizing manoeuvres to facilitate intubation and postoperative pharyngeal morbidity. Conclusion: In Clinicians who are well versed with laryngoscopy using Macintosh blade but new to Airtraq and ILMA, success rate of intubation is higher with ILMA. Prolonged intubation time in ILMA should not deter its use in difficult airway scenarios because of the ability to ventilate through it.

Role of Perioperative Surgical Safety Checklist in Reducing Morbidity and Mortality among Patients: An Observational Study.

BACKGROUND: Safe Surgery Saves Lives. Patient safety is a fundamental of good quality health care, and complications due to the health-care system are well-documented and constitute an important public health problem. Implementation of the checklist in medicine and surgery can help to decrease the risk of adverse events thus can improve patient safety. MATERIALS AND METHODS: After the Institutional Ethical Committee clearance, a total of 500 patients were enrolled and divided into two equal groups. In Group 1 (n = 250), patients underwent surgery before regular implementation of the World Health Organization (WHO) surgical safety checklist (SSC), whereas in Group 2 (n = 250), patients underwent surgery after the WHO SSC was regularly implemented. All the patients were followed up after the surgery, and patients were looked for and compared for the postoperative complications. RESULTS: We found that 27 patients (10.8%) in Group 1 and 13 patients (5.2%) in Group 2 developed major wound disruption (P < 0.05). There were 73 patients (29.2%) in Group 1 and 34 patients (13.6%) in the Group 2 who developed an infection of the surgical site (P < 0.05). There were five patients (2%) in Group 1 while none of the patients in Group 2 developed sepsis during the study (P < 0.05). CONCLUSIONS: We found that implementation of the WHO SSC significantly reduces surgical site infections, major disruptions of the wound, and sepsis.

Dexmedetomidine as an adjunctive analgesic to ropivacaine in pectoral nerve block in oncological breast surgery: A randomized double-blind prospective study.

BACKGROUND AND AIMS: Pectoral nerve block (Pecs) using local anesthetic (LA) agent is a newer analgesic technique for breast surgeries. This study further evaluates the effect of addition of dexmedetomidine to LA agent on total duration of analgesia and postoperative morphine consumption. MATERIAL AND METHODS: A total of 60 American Society of Anesthesiologist Grade I and II female patients with age ≥18 years, scheduled for oncological breast surgery, were enrolled in the study. Patients were randomized into two equal groups of 30 each. Group R (n = 30) received ultrasound (US)-guided Pecs block with 30 ml of 0.25% ropivacaine. Group RD (n = 30 patients) received US-guided Pecs block with 30 ml of ropivacaine 0.25% and dexmedetomidine 1 µ/kg body weight. Duration of analgesia and total postoperative morphine consumption was noted in 24 h period. Unpaired t-test and Chi-square test were used for statistical analysis. RESULTS: A statistically highly significant increase in total duration of analgesia (in minutes) was recorded in Group RD as compared to Group R (469.6 ± 81.5 in Group RD and 298.2 ± 42.3 in Group R) (P = 0.000). Total postoperative morphine consumption in mg was also statistically significantly lower in Group RD as compared to Group R (14.8 ± 2.4 in Group RD and 21.6 ± 3.1 in Group R) (P = 0.000). No patient under study reported any adverse effects. CONCLUSION: Addition of 1 µ/kg dexmedetomidine to 0.25% ropivacaine for Pecs block increases the duration of analgesia and decreases postoperative morphine consumption.

New Visual Prostate Symptom Score versus International Prostate Symptom Score in Men with Lower Urinary Tract Symptoms: A Prospective Comparision in Indian Rural Population.

INTRODUCTION: Benign prostrate hyperplasia (BPH) is a leading source of healthcare problem in aging men around the world including India. Both International Prostate Symptom Score (IPSS) and New Visual Prostate Symptom Score (VPSS) are used to assess the lower urinary tracts symptoms (LUTSs) in men. The present study was planned to compare these two scores, IPSS and VPSS in Indian rural men prospectively and their efficacy was compared with urodynamic evaluation of the patients. MATERIALS AND METHODS: With Institutional Ethical Committee approval, this study was conducted on 100 patients having LUTS and BPH after obtaining written informed consent. Patients' educational status was noted. All the patients were requested to complete the IPSS and VPSS questionnaire, and they were correlated. The urodynamic study was performed on all the patients with uroflowmeter. Two parameters of uroflowmetry, Qmax (maximum urine flow rate expressed in ml/s) and Qavrg (average urine flow rate expressed in ml/s) were measured and correlated. RESULTS: Most of the patients (55%) in this study were uneducated. Out of 100 patients, 83% were able to fill the VPSS questionnaire without assistance as compared to only 40% patients in IPSS questionnaire (Z = 6.557, P < 0.001). There was a positive correlation between IPSS and VPSS total score in this study (r = 0.453 and P ≤ 0.001). It was noticed that IPSS Question 2 for frequency of urination had a positive correlation with VPSS Question 1 (day time frequency of urination) r = 0.645 (P = 0.000). Similarly, IPSS Question 7 for night frequency when compared with VPSS Question 2 (nocturia); the value for r was found to be 0.536 (P = 0.000). The IPSS Question 5 for straining when compared to the VPSS Question 3, i.e., the question for the strength of stream during micturition; the positive correlation was found to be 0.266 (P = 0.007). There was a negative correlation between IPSS total score and Qavrg with value - 0.368 (P = 0.000) and between IPSS total score and Qmax of - 0.433 (P = 0.000). A negative correlation is also noted between VPSS total score and Qavrg of value 0.497 (P = 0.000) and VPSS total score and Qmax of value - 0.719 (P = 0.000). CONCLUSION: VPSS correlates significantly with the IPSS to quantify the LUTS due to BPH. The VPSS can be used instead of the IPSS for the assessment of symptom severity in men with LUTS, who are illiterate or have limited education.

Evolving with modern technology: Impact of incorporating audiovisual aids in preanesthetic checkup clinics on patient education and anxiety.

BACKGROUND AND AIMS: Perioperative stress is an often ignored commonly occurring phenomenon. Little or no prior knowledge of anesthesia techniques can increase this significantly. Patients awaiting surgery may experience high level of anxiety. Preoperative visit is an ideal time to educate patients about anesthesia and address these fears. The present study evaluates two different approaches, i.e., standard interview versus informative audiovisual presentation with standard interview on information gain (IG) and its impact on patient anxiety during preoperative visit. SETTINGS AND DESIGN: This prospective, double-blind, randomized study was conducted in a Tertiary Care Teaching Hospital in rural India over 2 months. MATERIALS AND METHODS: This prospective, double-blind, randomized study was carried out among 200 American Society of Anesthesiologist Grade I and II patients in the age group 18-65 years scheduled to undergo elective surgery under general anesthesia. Patients were allocated to either one of the two equal-sized groups, Group A and Group B. Baseline anxiety and information desire component was assessed using Amsterdam Preoperative Anxiety and Information Scale for both the groups. Group A patients received preanesthetic interview with the anesthesiologist and were reassessed. Group B patients were shown a short audiovisual presentation about operation theater and anesthesia procedure followed by preanesthetic interview and were also reassessed. In addition, patient satisfaction score (PSS) and IG was assessed at the end of preanesthetic visit using standard questionnaire. STATISTICAL ANALYSIS USED: Data were expressed as mean and standard deviation. Nonparametric tests such as Kruskal-Wallis, Mann-Whitney, and Wilcoxon signed rank tests, and Student's t-test and Chi-square test were used for statistical analysis. RESULTS: Patient's IG was significantly more in Group B (5.43 ± 0.55) as compared to Group A (4.41 ± 0.922) (P < 0.001). There was significant reduction in total anxiety from the baseline values in both the groups. This reduction was significantly more in Group B (8.47 ± 1.861) as compared to Group A (9.29 ± 1.616) (P < 0.001). PSS was also more in Group B (29.27 ± 2.378) as compared to Group A (25.62 ± 1.745) (P < 0.001). CONCLUSION: Audiovisual presentation provides unhurried, detailed, and reliable information about the perioperative environment and anesthesia procedure. This helps in significant IG and reduction of patient anxiety.

Video laryngoscope as an assist tool in lateral position laryngoscopy.

Difficult airway is one of the most challenging situations invariably encountered in modern anesthesia practice and requires a high level of skill. This case report highlights the use of video laryngoscopy as an assist device for lateral position intubation in a patient with a large lumbar mass who was unable to lie supine. This case emphasis the significance of careful approach to planning and preparation in the management of airway in such a case.

Effect of dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block: A randomized double-blind prospective study.

BACKGROUND AND AIMS: Regional anesthesia is a recommended technique for upper and lower limb surgeries with better postoperative profile. In this, randomized, double-blind study, we evaluated the effectiveness of the addition of dexmedetomidine to varying concentration of levobupivacaine for supra clavicular brachial plexus block. MATERIAL AND METHODS: After obtaining ethical Committee approval, a double-blind, randomized prospective clinical study was conducted on 90 American Society of Anesthesiologist Grade I and II patients in the age group of 18-55 years, divided randomly into two groups: Group A received 40 ml of solution containing 30 ml 0.5% levobupivacaine and 10 ml 1% lignocaine and group B received 40 ml of solution containing 30 ml 0.25% levobupivacaine and 10 ml 1% lignocaine with dexmedetomidine 1 microg/kg for supraclavicular brachial plexus block. Besides effectiveness, other parameters observed were: duration of sensory blockade; onset and duration of motor blockade; duration of postoperative analgesia; and patient satisfaction score. RESULTS: Onset of sensory and motor blockade was 7.6 ± 1.006 min and 8.3 ± 0.877 min in group A, while it was 6.96 ± 1.077 min an 7.6 ± 1.1 min in group B, respectively. The difference was statistically significant (P < 0.05). Duration of sensory block was 8.5 ± 0.77 h in group A and 8.5 ± 0.98 in group B (P > 0.05). Duration of motor block was 8.45 ± 0.75 h in group A and 5.6 ± 0.98 in group B (P < 0.05). Duration of analgesia was 8.5 ± 0.77 h in group A and 9.2 ± 1.05 in group B (P < 0.05). CONCLUSION: Addition of 1 microg/kg dexmedetomidine to 0.25% levobupivacaine for supraclaviclar plexus block shortens sensory, motor block onset time and motor block durations, extends sensory block, and analgesia durations. Reduction in total levobupivacaine dose also increases the safety margin of the block.

Cauda equina syndrome after repeated spinal attempts: A case report and review of the literature.

Spinal and epidural blocks are widely used for cesarean section. Spinal hematoma causing cauda equina syndrome is a rare complication after spinal anesthesia (SA), but can lead to severe neurological deficit. It is usually associated with difficult SA and requires surgical decompression in most of the cases.

Spontaneous pneumomediastinum with pneumopericardium, surgical emphysema, pneumothorax, and epidural pneumotosis: A rare association.

Pneumomediastinum is usually associated with subcutaneous emphysema and pneumopericardium, but rarely associated with pneumothorax and epidural pneumotosis. We report extremely rare simultaneous occurrence of self-limiting pneumomediastinum, pneumopericardium, surgical emphysema, pneumothorax, and epidural pneumotosis in an 18-year-old gentleman in the absence of identifiable cause.

Dilated cardiomyopathy: an anaesthetic challenge.

Idiopathic dilated cardiomyopathy is a primary myocardial disease of unknown etiology characterized by left ventricular or biventricular dilation and impaired contractility. Depending upon diagnostic criteria used, the reported annual incidence varies between 5 and 8 cases per 100,000 populations. Dilated cardiomyopathy is defined by presence of: a) fractional myocardial shortening less than 25% (>2SD) and/or ejection fraction less than 45% (>2SD) and b) Left Ventricular End Diastolic Diameter (LVEDD) greater than 117% excluding any known cause of myocardial disease. Such cases are always a challenge to the anesthesiologist as they are most commonly complicated by progressive cardiac failure. We report the anesthetic management of a patient with dilated cardiomyopathy undergoing surgery for carcinoma breast.

Evaluation of spinal and epidural anaesthesia for day care surgery in lower limb and inguinoscrotal region.

BACKGROUND: Day care surgery is still in its infancy in India. Both regional and general anaesthesia can be used for this. Central neuraxial blocks are simple cheap and easy to perform. This study was done to evaluate usefulness of spinal and epidural anaesthesia for day care surgery. PATIENTS #ENTITYSTARTX00026; METHOD: 100 patients were randomized to either spinal (n=50) or epidural (n=50) group anaesthetized with either 0.5% hyperbaric 2ml bupivacaine or 0.5% 20ml bupivacaine respectively. In spinal group 27 gauze quincke needle and in epidural group 18 gazue tuohy needle was used. Both the groups were compared for haemodynamic stability, side effects, complications, postanaesthesia discharge score (PADS), time taken to micturate, total duration of stay in hospital and patient satisfaction score for technique. RESULTS: We observed that spinal anaesthesia had significantly early onset of anaesthesia and better muscle relaxation (p<0.05) as compared to epidural block otherwise both groups were comparable for haemodynamic stability, side effects or complications. Although more patients in spinal group (64% vs 48%) achieved PADS earlier (in 4-8 hours) but statistically it was insignificant. Time to micturition (6.02 0.55 v/s 6.03 0.47 hours) and total duration of stay (7.49 1.36 v/s 8.03 1.33 hours) were comparable in both the groups. CONCLUSION: Both spinal and epidural anaesthesia can be used for day care surgery. Spinal anaesthesia with 27 gauze quincke needle and 2ml 0.5% hyperbaric bupivacaine provides added advantage of early onset and complete relaxation.