Comparison of Postoperative Pain and Analgesia Requirement among Diabetic and Nondiabetic Patients undergoing Lower Limb Fracture Surgery - A Prospective Observational Study.

Background: Diabetic patients usually experience neuropathic pain and have a decreased response to opioids. Fractures are acute conditions and as such, they are very painful. No data is available related to fracture and postoperative pain in diabetics. Aim: This study was conducted to evaluate postoperative pain and analgesics requirement among diabetic and nondiabetic patients undergoing lower limb fracture surgery and the effect of glycosylated hemoglobin (HbA1c) on the postoperative pain. Setting and Design: This was a prospective observational study, conducted on 80 patients comprising of nondiabetic and diabetic, scheduled for elective lower limb fracture surgery under spinal anesthesia. Materials and Methods: HbA1c was done in all the patients who were included in the study. Postoperative Visual Analog Scale (VAS) and analgesic consumption were assessed by an anesthesiologist blinded to the diabetic or nondiabetic status of the patients. VAS was assessed every 2nd hourly, for 24 h and rescue analgesia was given if the VAS was ≥4 and record was maintained. Sedation scores and adverse effects were also recorded postoperatively. Statistical Analysis: The Chi-square test was used for the analysis of categorical variables and Student's t-test was used for continuous variables. Results: Diabetic group of patients had a significantly high VAS score with P ≤ 0.05. Rescue analgesics requirement was significantly different in two groups with diabetic patients requiring more supplementation of analgesia with a P = 0.025. The overall patient satisfaction was lesser in diabetic group (P = 0.004). There was statistically significant correlation between glycosylated hemoglobin and VAS at 2nd, 16th, 18th, 20th, 22nd, and 24th h. Conclusion: Postoperative pain and analgesic requirement was significantly higher in diabetic patients with lower limb fracture. Glycosylated hemoglobin had good correlation with higher VAS.

Sphenopalatine ganglion block: Intranasal transmucosal approach for anterior scalp blockade - A prospective randomized comparative study.

BACKGROUND AND AIMS: Peripheral nerve blocks in neurosurgical practice attenuate most stressful responses like pin insertion, skin, and dural incision. Scalp block is conventionally the blockade of choice. Further studies for less invasive techniques are required. Intranasal transmucosal block of the sphenopalatine ganglion has shown promising results in patients with chronic headache and facial pain. The primary objective of our study was to compare the gold standard scalp block and bilateral sphenopalatine ganglion block (nasal approach) for attenuation of hemodynamic response to pin insertion. Secondary objectives included hemodynamic response to skin and dural incision. MATERIAL AND METHODS: After IRB approval and informed consent, a prospective randomized comparative study was carried out on 50 adult patients undergoing elective supratentorial surgery. The hemodynamic response to pin insertion, skin incision, and dural incision was noted in both the groups. The data was analyzed with NCSS version 9.0 statistical software. RESULTS: The HR and MAP were comparable between the groups. Following dural incision MAP was significantly lower at 1,2,3,4,5 and 10 min in group SPG whereas in group S it was significantly lower at 1 and 2min. (P = 0.02 at T1, P = 0.03 at T2). CONCLUSIONS: Concomitant use of bilateral SPG block with general anesthesia is an effective and safe alternative technique to scalp blockade for obtundation of hemodynamic responses due to noxious stimulus during craniotomy surgeries.

Enhanced recovery after surgery: An anesthesiologist's perspective.

Enhanced recovery after surgery (ERAS) protocols are a combination of multimodal evidence-based strategies, applied to the conventional perioperative techniques, to reduce postoperative complications and to achieve early recovery. These strategies or protocols, require a dedicated and organized team effort for their implementation to enable early discharge and thus reduce the length of hospital stay. Anesthesiologists play an important role in facilitating these protocols as some of the key elements such as preoperative patient preparation and assessment, perioperative fluid management, and perioperative pain relief are handled by them. This article discusses in detail the various components of ERAS and the anesthesiologist's role in implementing them.

Does Parsonnet scoring model predict mortality following adult cardiac surgery in India?

AIMS AND OBJECTIVES: To validate the Parsonnet scoring model to predict mortality following adult cardiac surgery in Indian scenario. MATERIALS AND METHODS: A total of 889 consecutive patients undergoing adult cardiac surgery between January 2010 and April 2011 were included in the study. The Parsonnet score was determined for each patient and its predictive ability for in-hospital mortality was evaluated. The validation of Parsonnet score was performed for the total data and separately for the sub-groups coronary artery bypass grafting (CABG), valve surgery and combined procedures (CABG with valve surgery). The model calibration was performed using Hosmer-Lemeshow goodness of fit test and receiver operating characteristics (ROC) analysis for discrimination. Independent predictors of mortality were assessed from the variables used in the Parsonnet score by multivariate regression analysis. RESULTS: The overall mortality was 6.3% (56 patients), 7.1% (34 patients) for CABG, 4.3% (16 patients) for valve surgery and 16.2% (6 patients) for combined procedures. The Hosmer-Lemeshow statistic was <0.05 for the total data and also within the sub-groups suggesting that the predicted outcome using Parsonnet score did not match the observed outcome. The area under the ROC curve for the total data was 0.699 (95% confidence interval 0.62-0.77) and when tested separately, it was 0.73 (0.64-0.81) for CABG, 0.79 (0.63-0.92) for valve surgery (good discriminatory ability) and only 0.55 (0.26-0.83) for combined procedures. The independent predictors of mortality determined for the total data were low ejection fraction (odds ratio [OR] - 1.7), preoperative intra-aortic balloon pump (OR - 10.7), combined procedures (OR - 5.1), dialysis dependency (OR - 23.4), and re-operation (OR - 9.4). CONCLUSIONS: The Parsonnet score yielded a good predictive value for valve surgeries, moderate predictive value for the total data and for CABG and poor predictive value for combined procedures.

Unanticipated cannot intubate situation due to difficult mouth opening.

We report a case of unanticipated difficult endotracheal intubation secondary to an abrupt onset of difficulty in opening the mouth in an anesthetized adult. A female aged 76 years with American Society of Anesthetists risk Class IV E with an apparently normal preoperative temporomandibular joint was scheduled for emergency laparotomy. Following rapid sequence induction, and muscle relaxation with rocuronium, the anesthesiologist noticed lock-jaw when intubation was attempted. She was ventilated with nasopharyngeal airway, but was progressively desaturating. An emergency tracheostomy was performed. Unfortunately, she sustained cardiac arrest and could not be revived. The complication of the lock-jaw is a nightmare to airway management, especially in an unprepared situation.

Effect of rigid cervical collar on tracheal intubation using Airtraq(®).

BACKGROUND AND AIMS: Cervical spine immobilisation with rigid cervical collar imposes difficulty in intubation. Removal of the anterior part of the collar may jeopardize the safety of the cervical spine. The effect of restricted mouth opening and cervical spine immobilisation that result from the application of rigid cervical collar on intubation using Airtraq(®) was evaluated. METHODS: Seventy healthy adults with normal airways included in the study were intubated Using Airtraq® with (group C) and without rigid cervical collar (group NC). The ease of insertion of Airtraq(®) into the oral cavity, intubation time, intubation difficulty score (IDS) were compared using Wilcoxon sign ranked test and McNemar test, using SPSS version 13. RESULTS: Intubation using Airtraq(®) was successful in the presence of the cervical collar in 96% which was comparable to group without collar (P = 0.24). The restriction of mouth opening resulted in mild difficulty in insertion of Airtraq(®). The median Likert scale for insertion was - 1 in the group C and + 1 in group NC (P < 0.001). The intubation time was longer in group C (30 ± 14.3 s vs. 26.9 ± 14.8 s) compared to group NC. The need for adjusting manoeuvres was 18.5% in group C versus 6.2% in group NC (P = 0.003) and bougie was required in 12 (18.5%) and 4 (6.2%) patients in group C and NC, respectively, to facilitate intubation (P = 0.02). The modified IDS score was higher in group C but there was no difference in the number of patients with IDS < 2. CONCLUSION: Tracheal intubation using Airtraq(®) in the presence of rigid cervical collar has equivalent success rate, acceptable difficulty in insertion and mild increase in IDS.