A Randomized Control Study to Assess the Efficacy of Intrathecal Morphine in Patients on Patient-Controlled Analgesia Pump With Morphine for Postoperative Pain Relief After Elective Laparotomy.

Introduction Laparotomy is associated with significant prolonged postoperative pain, which can cause an adverse neuroendocrine stress response. Intrathecal morphine (ITM) retains an important place in pain management after major laparotomy since it is easier to administer and has a relatively lesser possibility of failure and technical difficulty. Aim The study aims to compare the effect of the administration of ITM with intravenous (IV) morphine administered by a patient-controlled analgesia (PCA) pump on postoperative analgesia after elective laparotomy. The primary objective was to compare total morphine consumption while secondary objectives were to compare pain assessed by the visual analog scale (VAS) and adverse reactions to opioids. Methods Sixty patients who underwent elective laparotomy were enrolled in this study. Thirty patients were enrolled in the study group (ITM+PCA) where ITM (200 mcg) was administered before laparotomy and intravenous morphine was initiated with PCA postoperatively. In the control group, only intravenous morphine was given with PCA postoperatively for pain relief. Parameters in both groups were compared, where estimation of cumulative morphine dose was the primary outcome and pain as assessed by VAS and side effects of opioids were the secondary outcomes. Results Patients in the ITM (ITM+PCA) group required less morphine (6.6 ± 2.96 vs. 24.77 ± 6.79 mg of morphine, p < 0.001) compared to patients on PCA. There was no statistically significant difference in VAS score and adverse effects between both groups. Conclusion Preoperative ITM can be used as an effective and safe modality for alleviating immediate postoperative pain following laparotomy.

Assessment of haemodynamic response to tracheal intubation and prone positioning following clonidine and enalaprilat in lumbar spine surgeries: A double blind randomised controlled trial.

Background and Aim: This study evaluates the effectiveness of long-acting antihypertensive drugs (clonidine and enalaprilat) in blunting the intubation response. Also, the study seeks to determine how effectively clonidine and enalaprilat can maintain stable haemodynamics during a change in position. Methods: After ethical committee approval and trial registration, a double-blinded, randomised controlled trial was conducted with 71 consenting patients scheduled for elective spine surgery in a prone position under general anaesthesia. Group C received clonidine 2 µg/kg, and Group E received enalaprilat 1.25 mg diluted in normal saline as an intravenous infusion given over 10 min before induction of anaesthesia. The changes in heart rate (HR) and blood pressure (BP) in response to the infusion of the study drugs, induction, tracheal intubation and change in position were recorded. P value <0.05 was considered significant. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 25. Results: Clonidine infusion caused a significant fall in heart rate post-infusion and post-induction with propofol (p value <0.05). Both clonidine and enalaprilat caused a significant fall in mean arterial pressure (MAP) post-infusion and post-induction (p value <0.05). Clonidine effectively blunted the intubation response with no increase in HR and MAP following intubation. Enalaprilat caused a significant rise in HR in response to intubation. On proning, there was a significant fall in MAP in both groups. Conclusion: Clonidine is effective in blunting the intubation response. Preoperative infusion of clonidine and enalaprilat causes hypotension during a change of position.

A Comparison Between the Effects of Single-Dose Oral Gabapentin and Oral Clonidine on Hemodynamic Parameters in Laparoscopic Surgeries: A Randomized Controlled Trial.

Background and objective Laparoscopic surgeries can result in exaggerated sympathetic responses due to pneumoperitoneum. Many drugs including clonidine and gabapentin have been evaluated to attenuate the hemodynamic response to abdominal insufflation. In light of this, this study was conducted to compare the effects of preoperative administration of oral gabapentin with those of clonidine on intraoperative hemodynamic parameters in patients undergoing laparoscopic surgeries. Methodology A prospective, randomized, double-blinded comparative trial spanning a period of one year was conducted involving 150 patients scheduled to undergo elective laparoscopic surgeries at a tertiary hospital. Patients who fulfilled the inclusion criteria were randomly allocated into three groups: to receive oral gabapentin 300 mg (Group G) or oral clonidine 150 mcg (Group CL) or a placebo tablet (Group C). Standard anesthetic protocols were followed during the surgery and the mean arterial pressure (MAP), heart rate (HR), postoperative pain as assessed by visual analog scale (VAS) scores, postoperative analgesic consumption, sedation scores, and complications like nausea, vomiting, and dry mouth were recorded and analyzed. Results HR and MAP were significantly reduced in the intervention groups (clonidine and gabapentin) compared to the control group. There was a statistically significant reduction in MAP and HR in patients on oral clonidine compared to patients on gabapentin. Postoperative pain as assessed by VAS score was better in the intervention groups compared to patients who were administered a placebo. Postoperative analgesic consumption was significantly lower in patients on clonidine and gabapentin compared to the control group. Patients on oral gabapentin received lower doses of tramadol compared to patients on clonidine. Postoperative sedation as assessed by the Ramsay sedation scale (RSS) score was higher in patients on oral gabapentin. Complications like postoperative nausea and vomiting were significantly reduced in the intervention groups, while dryness of mouth was more prevalent in patients on clonidine. Conclusion Based on our findings, oral clonidine is more effective in attenuating hemodynamic response to pneumoperitoneum compared to oral gabapentin. Postoperative pain was lower in intervention groups compared to the control group. However, patients on gabapentin required a lower dose of analgesics postoperatively compared to patients on clonidine. Postoperative sedation was also more pronounced in patients on gabapentin while dryness of mouth was more common in patients on oral clonidine.

Coagulation conundrum in obstetric anesthesia with COVID-19.

Coronavirus disease (COVID-19) pandemic is an unprecedented public health calamity that has caused an immense setback to maternal health services in developing countries. In addition to morbidity and mortality caused by COVID-19 disease in parturient directly, the indirect adverse impact of lockdown imposed during pandemic causing loss of follow-up of patients with coexisting illness is significant. There are no standard protocols to manage COVID-19 patients with comorbid medical illness, who are not optimized during antenatal visits. We report an interesting case of an antenatal patient with COVID-19, with prosthetic aortic valve on warfarin with elevated International Normalized Ratio (INR) and severe pre-eclampsia, posted for emergency cesarean section.

Delayed diagnosis of traumatic diaphragmatic rupture with herniation of the liver: a case report.

Diaphragmatic rupture is a potentially life-threatening clinical situation. It occurs as a result of high-velocity blunt or penetrating injury to the abdomen and thorax. Acute traumatic rupture of the diaphragm may go undetected, and there is often a delay between the injury and diagnosis. Right-sided rupture is less common due to hepatic protection and increased strength of the right hemidiaphragm. We report the case of a 28-year-old man who was admitted with breathlessness to our hospital, 72 hours after trauma. Since clinical signs and symptoms were nonspecific, helical computed tomography was done, which revealed diaphragmatic rupture with hepatothorax. Emergency thoracotomy was done to repair diaphragmatic rent. The postoperative period was uneventful, and the patient was discharged three weeks later.

Comparison of bougie-guided insertion of Proseal laryngeal mask airway with digital technique in adults.

The Proseal laryngeal mask airway (PLMA, Laryngeal Mask Company, UK) was designed to improve ventilatory characteristics and offer protection against regurgitation and gastric insufflation. The PLMA is a modified laryngeal mask airway with large ventral cuff, dorsal cuff and a drain tube. These modifications improve seal around glottis and enable better ventilatory characteristics. The drain tube prevents gastric distension and offers protection against aspiration. There were occasional problems, like failed insertion and inadequate ventilation, in placing PLMA using the classical digital technique. To overcome these problems, newer placement techniques like thumb insertion technique, introducer tool placement and gum elastic bougie (GEB)-aided placement were devised. We compared classical digital placement of PLMA with gum elastic bougie-aided technique in 60 anaesthetised adult patients (with 30 patients in each group) with respect to number of attempts to successful placement, effective airway time, airway trauma during insertion, postoperative airway morbidity and haemodynamic response to insertion. The number of attempts to successful placement, airway trauma during insertion and haemodynamic response to insertion were comparable among the two groups, while effective airway time and oropharyngeal leak pressure were significantly higher in bougie- guided insertion of PLMA. Postoperatively, sore throat was more frequent with digital technique while dysphagia was more frequent with bougie guided technique. Hence gum elastic bougie guided, laryngoscope aided insertion of PLMA is an excellent alternate to classical digital technique.