Newer frontiers in onco-anaesthesia and palliative medicine.

Despite an increase in knowledge on the biology of cancer and newer therapeutic modalities, the incidence and mortality of cancer continue to rise. Interventions to enhance perioperative outcomes in cancer is a growing research area that targets early recovery and initiation of cancer-specific treatment. Increasing mortality in non-communicable diseases such as cancer mandates an integrated palliative care for these patients to achieve the best possible quality of life. The aim of this review is to discuss in brief the advancements in onco-anaesthesia and palliative medicine that have helped improve oncological outcomes and the quality of life of patients.

An observational study to evaluate the prescription pattern of analgesics used in the perioperative period in a tertiary care hospital.

BACKGROUND AND AIMS: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. There are limited observational prescription pattern studies of analgesics in perioperative period in tertiary care hospitals for which this study was carried out in orthopedic, general surgery, and plastic surgery departments. The primary aim was to study the prescription pattern of analgesics in the perioperative period with the secondary aim to study the specific use of opioids and pain relief using the Visual Analog Scale (VAS). METHODS: A total of 250, 250, and 100 patients were taken from orthopedic, general surgery, and plastic surgery departments, respectively. The analgesics commonly used in preoperative, intraoperative, and postoperative period were observed. The use of opioids in the perioperative period, the number of fixed drug combinations used, the number of generic drug prescription, and pain relief postoperatively were also observed. The analysis was done using descriptive statistics. RESULTS: Total analgesics prescribed were 1168, 117, and 369 in orthopedic, general surgery, and plastic surgery departments, respectively, and were maximum in the intraoperative period. Most commonly used analgesic in the preoperative and postoperative period was paracetamol and that in intraoperative period was fentanyl. Nonsteroidal anti-inflammatory drugs (NSAIDs) were mainly prescribed by the general surgery department in postoperative period. The amount of pain in postoperative period after treatment with analgesics was mild to moderate as per the VAS. CONCLUSION: This study revealed that in preoperative and postoperative period, the most common analgesic used is paracetamol. In the intraoperative period, maximum patients received fentanyl. Diclofenac is an established NSAID used in the management of acute and chronic pain states. In our study, we found that the usage of paracetamol was more than NSAIDs and the usage of opioid was maximum during intraoperative period.

Assessment of communication skill during process of preoperative visit and informed consent by anesthesiology residents.

Background and Aims: Anaesthesiologists have few opportunities to communicate with patients especially in preoperative period for various reasons. If these opportunities are not well utilized, anesthesiologists may not be able to educate patients about anaesthesia related issues. The aim of this study was to assess communication skill (CS) exhibited by the anesthesiology residents during the process of preoperative visit and informed consent. Material and Methods: This was a pre and post intervention questionnaire based study carried out in a presurgical ward of a tertiary hospital. During the process of preoperative visit and informed consent, fourteen of the second year anesthesia residents were assessed by faculty members for various aspects of CS using validated questionnaire on 3-point Likert's scale, before and after CS workshop. Residents' perception about workshop and patient satisfaction with regards to the preoperative visit and process of informed consent was assessed. Results were described in percentage value and a qualitative analysis was carried out. Results: While none of the residents exhibited 'excellent CS score' in the pre-workshop phase, six (42.86%) achieved the same after the workshop. One resident, who had 'poor CS score' moved to higher category score post workshop. The behavioural traits of professionalism, empathy, risk explanation and written consent showed statistically significant improvements post intervention by Wilcoxon Signed Rank Test, with P value < 0.05. All residents felt that good communication can improve patient satisfaction and CS training should be part of the post graduate curriculum. Conclusion: Conduct of CS workshop for anesthesia residents improved certain behavioral traits during anaesthesia preoperative visit and informed consent process. This important nontechnical skill of CS, may not be uniformly acquired during clinical training and should be specifically taught and evaluated as part of post graduate curriculum.

Total intravenous anaesthesia with tumescent infiltration anaesthesia without definitive airway for early excision and skin grafting in a major burn - A prospective observational study.

BACKGROUND AND AIMS: Patients with major burns posted for early tangential excision and skin grafting pose peculiar challenges for anaesthesiologists. The purpose of the study was to assess safety and efficacy of total intravenous anaesthesia (TIVA) with tumescent infiltration anaesthesia (TIA) for these burn procedures. METHODS: This observational single-arm study was conducted on 48 cases of a tertiary centre burn unit, requiring early tangential excision and skin grafting between third and fifth days of burn injury. TIVA was administered using a combination of intravenous (iv) infusion of injection dexmedetomidine and iv boluses of fentanyl, ketamine, propofol, midazolam and paracetamol. TIA was administered in burn wounds after aseptic preparation. Spontaneous breathing was maintained with oxygen supplementation. Haemodynamic and respiratory monitoring was done intraoperatively every 15 minutes and for 6 hours postoperatively. Modified Aldrete's score was calculated at 10 minutes after completion of surgery. Statistical analysis was done using statistical package for the social science software (version 16). Descriptive statistics were used for quantitative variables. RESULTS: Baseline mean HR was 106.95 ± 11.17 bpm (beats per minute). HR settled at 73.17 ± 6.97 bpm during the intraoperative period. The baseline mean arterial pressure (MAP) of 82.42 ± 10.04 mmHg was maintained at 81 ± 7.32 mmHg during the intraoperative period. In all, 95.8% achieved early recovery with mean modified Aldrete's score of ≥9 at 10 minutes post-surgery. There was no episode of apnoea or desaturation. CONCLUSION: TIVA in combination with TIA minimally interferes with homeostasis and promotes early recovery in patients undergoing early excision and grafting in major burns.

Impact of basic medical writing workshop on case report writing by post-graduate anaesthesia trainees: A pilot study.

BACKGROUND AND AIMS: Research is an integral component of medical education and practice. However, the art of medical writing remains neglected. Case report writing marks foray into the world of publications and presentations. We assessed and compared the impact of basic medical writing workshop about case report writing and their perception levels of confidence in these skills, among post-graduate anaesthesia students. METHODS: A needs assessment for medical writing skills was performed among all anaesthesia residents. A total of 20 students were enrolled in this study. The pre-workshop assignment consisted of writing one case report per participant within 30 days, followed by students' confidence assessment in these skills. A workshop on basic medical writing including analytical writing, scientific writing and plagiarism were conducted. Post-workshop a similar assignment was provided, followed by students' confidence assessment. RESULTS: Moderate-to-high need for help was felt by 92.63% for analytical skills, 100% for scientific skills and writing without plagiarism, 95.78% for overall writing skills. For case report writing, the analytical and scientific writing significantly improved after the workshop (P = 0.01 and P = 0.016, respectively). There was a significant improvement in the students' confidence levels post-workshop in their analytical writing skills, avoiding plagiarism and overall writing capabilities (P = 0.02, P = 0.016 and P = 0.002, respectively). CONCLUSION: Writing skills of participants and their confidence in these skills improved post-workshop.

Evaluation of oral multi-herbal preparation of Dashmoolarishta on mice model of osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a chronic progressive disease commonly affecting the hip and knee joints. Although synthetic drugs are available and afford symptomatic relief, their side effects pose limitations to their continuous use. So, this research was focused on extracting drugs from indigenous medicinal plants that could have a beneficial effect on osteoarthritis. Dashmoolarishta is one such preparation whose effects have never been studied in comparison with recent drugs like hyaluronic acid (HA), hence this particular study was undertaken. The aim of this study was to evaluate the effects of Dashmoolarishta compared with HA on joint pathology and pain behavior in monosodiumiodoacetate (MIA)-induced OA in experimental mice. METHODS: The study was initiated after obtaining permission from the Animal Ethics Committee. This study was based on the MIA model of osteoarthritis, with mice being divided into five groups viz.: disease control (DC), Dasahmoolarishta high dose (HD) and low dose (LD), sham control (SC) and HA. The OA of the knee joint was induced in these mice using monosodiumiodoacetate. Seven days after induction, animals were subjected to weekly behavioral tests, daily oral Dashmoolarishta, and biweekly HA administration from weeks 2-4. At the end of the 4th week, histopathological examination of the knee joints was done. RESULTS: DC showed significant osteoarthritic changes. At week 4, the behavioral tests and histopathology results of all groups were found to be significant. A significant difference (p<0.05) was found between DC vs. SC, HA, HD, LD for open field test, Rota rod test, knee joint diameter, and Cat walk test. Dashmoolarishta HD and LD showed significant improvement in pain, as assessed by behavioral tests (p<0.05) and pathology, as assessed by knee joint histopathology (p<0.05). CONCLUSIONS: Oral Dashmoolarishta showed reduction in pain and disease activity in MIA-induced osteoarthritis in mice model.

Intra-articular injections of ketamine and 25% dextrose improve clinical and pathological outcomes in the monosodium iodoacetate model of osteoarthritis.

BACKGROUND: The study evaluated the effect of intra-articular injections of ketamine and 25% dextrose with triamcinolone acetate (TA) and hyaluronic acid (HA) on joint pathology and pain behavior in monosodium iodoacetate (MIA)-induced osteoarthritis (OA) in experimental mice. METHODS: In phase I, the MIA-induced OA model was standardized. In phase II, mice were divided into three groups: disease controls (DC), ketamine 12 mg/kg (K12) and ketamine 24 mg/kg (K24) to select an effective dose of ketamine for phase III. In phase III, the groups were: DC, normal controls (NC), K24, 25% dextrose (D25) - 10 µL, TA 6 mg/kg, and HA - 3.5 mg/kg. The effect of ketamine was compared with the standard drugs - TA and HA. In phases II and III, after 7 days following the induction of OA, animals were subjected to weekly behavioral tests and biweekly drug administration from week 2 to week 4. Subsequently, after 4 weeks knee joint samples were collected and sent for histopathological evaluation to a veterinary pathologist. RESULTS: In phase I, the DC group showed significant OA changes as compared to NC on knee joint histopathology scoring. In phase II, all the behavioral tests and knee joint histopathology results demonstrated a significant improvement with K24 as compared to DC. In phase III, significant differences were found between DC vs. HA, DC vs. D25, DC vs. K24, K24 vs. TA, HA vs. TA for open field test and hot plate test (p<0.001), whereas HA and ketamine showed comparable results for these tests. There was a significant improvement in D25, TA and K24, HA groups as compared to DC in histopathology scores, (p<0.05). CONCLUSIONS: The NMDA antagonist effect of ketamine and the proliferative effect of 25% dextrose showed a reduction in pain and disease activity in the OA model.

Drug utilisation and off-label use of medications in anaesthesia in surgical wards of a teaching hospital.

BACKGROUND AND AIMS: When a drug is used in a way that is different from that described in regulatory body approved drug label, it is said to be 'off label use'. Perioperative phase is sensitive from the point of view of patient safety and off-label drug use in this setup can prove to be hazardous to patient. Hence, it was planned to assess the pattern of drug utilisation and off-label use of perioperative medication during anaesthesia. METHODS: Preoperatively, demographic details and adverse events check list were filled from a total of 400 patients from general surgery, paediatric surgery and orthopaedics departments scheduled to undergo surgery. The perioperative assessment form was assessed to record all prescriptions followed by refilling of adverse events checklist in case record form. World Health Organization (WHO) prescribing indicators were used for analysis of drug utilisation data. National Formulary of India 2011 was used as reference material to decide off-label drug use in majority instances along with package insert. RESULTS: A total of 3705 drugs were prescribed to the 400 participants and average number of drugs per patient was 9.26 ± 3.33. Prescriptions by generic name were 68.07% whereas 85.3% drugs were prescribed from hospital schedule. Off-label drugs overall formed 20.19% of the drugs prescribed. At least one off-label drug was prescribed to 82.5% of patients. Inappropriate dose was the most common form of off-label use. There was 1.6 times greater risk of occurrence of adverse events associated with the use of off-label drugs. CONCLUSION: Prescription indicators were WHO compliant. Off-label drug use was practiced in anaesthesia department with questionable clinical justification in some instances.

Segmental thoracic spinal anesthesia in patient with Byssinosis undergoing nephrectomy.

Byssinosis is an occupational disease occurring commonly in cotton mill workers; it usually presents with features of chronic obstructive pulmonary disease (COPD). The management of patients with COPD presents a significant challenges to the anesthetist. Regional anesthesia is preferred in most of these patients to avoid perioperative and postoperative complications related to general anesthesia. We report a known case of Byssinosis who underwent nephrectomy under segmental spinal anesthesia at the low thoracic level.