The analgesic efficacy of ultrasound-guided transversus abdominis plane block vs. local anesthetic infiltration technique in major gynecologic surgery: A randomized controlled trial.

Background and Aim: Transversus abdominis plane (TAP) block and local anesthetic infiltration (LAI) technique are used as part of the multimodal analgesic regimen after abdominal surgery. Postoperative opioid consumption and analgesic efficacy was compared using TAP and LAI techniques in patients undergoing gynecologic surgery in a randomized, controlled clinical trial. Material and Methods: Total of 135 patients scheduled for major gynecological surgeries were allocated into three groups: group T received bilateral TAP block with bupivacaine 0.25%; group I received LAI with 0.25% bupivacaine with epinephrine 5 µ/mL in the peritoneum and abdominal wall, and group C was control group. Anesthesia and postoperative analgesia were standardized. Outcome measures were cumulative and rescue tramadol consumption, numerical rating score (NRS) for pain and side effects in post-anesthesia care unit (PACU) at 4, 8, 12 hours postoperatively. Results: Tramadol consumption, need for rescue analgesia, and NRS for pain between three groups at 4, 8, and 12 hours postoperatively had no statistically significant difference (P < 0.05). In PACU, median tramadol consumption used for rescue analgesia between group T (15 (15-30)) and group C (30 (15-45)) (P = 0.035), and between group T (15 (15-30)) and group I (30 (15-52)) was statistically significant (P = 0.034). In PACU, the percentage of patients having NRS >4 on movement in group C (72%) compared to group T (46.5%) and group I (46.5%) was significant (P = 0.034). No statistically significant difference was observed in the incidence of side effects among study groups (P > 0.05). Conclusion: Except for the immediate postoperative period, neither TAP block nor LAI had added benefit to the multimodal analgesia regimen in patients undergoing gynecological surgeries.

Incidence and Predictors of Difficult Mask Ventilation in High-Risk Adult Population Scheduled for Elective Surgery: A Prospective Observational Study.

Introduction Mask ventilation is one of the key components in the management of airway during general anaesthesia, particularly when laryngoscopy is challenging. Adequate mask ventilation provides anaesthesiologists a safe time in case of unanticipated or anticipated difficult airway situations. The aim of this study was to determine the incidence of difficult bag-mask ventilation and intubation in patients having three or more predictors for difficult mask ventilation (DMV) in adult patients scheduled for elective surgery under anaesthesia. Methods A total of 294 patients requiring endotracheal intubation for elective surgical procedure having three or more risk factors were evaluated for the presence of difficulty in bag-mask ventilation and intubation by the anaesthesiologist. Chi-square test or Fisher's exact test and a multivariable stepwise logistic regression model were performed to identify predictors of DMV. Crude and adjusted odds ratio with 95% confidence interval were reported. Results In this study, the average age of the patients was 53.59±13.32 years with a 2:1 male-to-female ratio. DMV and difficult intubation (DI) were observed in 31.6% and 3% of patients, respectively. Multivariate analysis identified history of snoring, BMI (>35 kg/m2), presence of beard and Mallampati III or IV as independent predictors for DMV. Patients with multiple factors (≥3 factors) had a threefold (OR=2.57) increased risk of difficulty in mask ventilation and a nearly fivefold (OR=4.63) increased risk of difficulty with intubation. Conclusion  In our study, the incidence of DMV was observed in 93 (31.6%) patients and DI was found in 9 (3%) patients. A simple DMV risk score may help to predict DMV better, potentially improving safety during difficult airway management, decreasing morbidity and mortality associated with it.

Safety and rate of delayed adverse events with lumen-apposing metal stents (LAMS) for pancreatic fluid collections: a multicenter study.

Background and study aims Endoscopic drainage with dedicated lumen-apposing metal stents (LAMS) is routinely performed for symptomatic pancreatic fluid collections (PFCs), walled-off necrosis (WON) and pseudocyst (PP). There has been increasing concern regarding delayed adverse events associated with the indwelling LAMS.  Patients and methods Multicenter retrospective analysis of consecutive patients who underwent endoscopic ultrasound (EUS)-guided LAMS placement for PFC from January 2010 to May 2017. Main outcomes included: (1) resolution of the PFC, (2) rate of delayed adverse events at follow-up, and (3) predictors of treatment failure and delayed adverse events on logistic regression. Results A total of 122 patients (mean age 50.9 years, 68 % male) underwent LAMS insertion for 64 WON (98.4 %) and 58 PP (98.3 %). PFC mean size was 10.6 cm. PFC resolution was significantly lower for WON (62.3 %) vs. PP (96.5 %) ( P  < 0.001) on imaging at a median of 4 weeks. Stent occlusion was identified in 18 (29.5 %) and 10 (17.5 %) patients with WON and PP, respectively ( P  = 0.13). There were no cases of delayed bleeding or buried stent on follow-up endoscopy. Use of electrocautery-enhanced LAMS was the only factor associated with treatment failure of WON (OR = 13.2; 95 % ci: 3.33 - 51.82, P  = 0.02) on logistic regression. There were no patient, operator, or procedure-related factors predictive of stent occlusion. Conclusions EUS-guided LAMS for PFC is associated with a low incidence of delayed adverse events. While nearly all PPs resolve at 4 weeks permitting LAMS removal shortly thereafter, many WON persist, with use of electrocautery-enhanced LAMS being the sole predictor of treatment failure.

Postoperative pain management practices and their effectiveness after major gynecological surgery: An observational study in a tertiary care hospital.

BACKGROUND AND AIMS: Despite advances in postoperative pain management, patients continue to experience moderate to severe pain. This study was designed to assess the strategy, effectiveness, and safety of postoperative pain management in patients undergoing major gynecological surgery. MATERIAL AND METHODS: This observational study included postoperative patients having major gynecological surgery from February 2016 to July 2016. Data collected on a predesigned data collection sheet included patient's demographics, postoperative analgesia modality, patient satisfaction, acute pain service assessment of numeric rating scale (NRS), number of breakthrough pains, number of rescue boluses, time required for the pain relief after rescue analgesia, and any complication for 48 h. RESULTS: Among 154 patients reviewed, postoperative analgesia was provided with patient-controlled intravenous analgesia in 91 (59.1%) patients, intravenous opioid infusion in 42 (27%), and epidural analgesia in 21 (13.6%) patients with no statistically significant difference in NRS between different analgesic modalities. On analysis of breakthrough pain, 103 (66.8%) patients experienced moderate pain at one time and 53 (51.4%) at two or more times postoperatively. There were 2 (0.6%) patients experiencing severe breakthrough pain due to gaps in service provision and inadequate patient's knowledge. Moderate-to-severe pain perception was irrespective of type of incision and surgery. Vomiting was significantly higher (P = 0.049) in patients receiving opioids. CONCLUSION: Adequacy of postoperative pain is not solely dependent on drugs and techniques but on the overall organization of pain services. However, incidence of nausea and vomiting was significantly higher in patients receiving opioids.