Comparison of positive pressure extubation with traditional extubation in critically ill patients - a randomised control study.

BACKGROUND: Two extubation methods are commonly used in the intensive care unit (ICU): the traditional method with endotracheal suctioning and the positive- pressure method without suctioning. Better physiological outcomes were found in lab studies using the latter, as the air passing between the endotracheal tube and the larynx pushes out the collected subglottic secretions, which can be suctioned. METHODS: 70 mechanically ventilated patients in a tertiary ICU were randomised into 2 groups of 35 patients each. At the end of the spontaneous breathing trial (SBT), the positive pressure extubation (PPE) group was given a pressure support of 15 cm H 2 O and a positive end expiratory pressure of 10 cm H 2 O for 5 minutes while the other group (traditional extubation - TE) was extubated directly. We compared the lung ultrasound scores (LUS), chest X-ray findings, alveolar arterial oxygen gradient changes, adverse clinical events, ICU-free days and reintubation rates between the two groups. RESULTS: Median LUS at the end of the SBT was similar between the two groups. However, the median post-extubation LUS at 30 minutes, 6 hours, 24 hours in the PPE group [5 (4-8) ( P = 0.04), 5 (3-8) ( P = 0.02), 4 (3-7) ( P = 0.02), respectively] were significantly lower compared to the TE group [6 (6-8), 6 (5-7.5), 6 (5-7.5), respectively]. There was a persistent lowering of the scores even at the end of 24 hours in the PPE group, while the percentage of patients without adverse clinical events was significantly higher (80% vs. 57.14%, P = 0.04). CONCLUSIONS: The study shows that positive pressure extubation is a safe procedure which improves aeration and reduces adverse events.

A comparison of analgesic efficacy and safety of clonidine and methylprednisolone as additives to 0.25% ropivacaine in stellate ganglion block for the treatment of complex regional pain syndrome: a prospective randomised single blind study.

Background: The role of the sympathetic nervous system appears to be central in causing pain in complex regional pain syndrome (CRPS). The stellate ganglion block (SGB) using additives with local anesthetics is an established treatment modality. However, literature is sparse in support of selective benefits of different additives for SGB. Hence, the authors aimed to compare the efficacy and safety of clonidine with methylprednisolone as additives to ropivacaine in the SGB for treatment of CRPS. Methods: A prospective randomized single blinded study (the investigator blinded to the study groups) was conducted among patients with CRPS-I of the upper limb, aged 18-70 years with American Society of Anaesthesiologists physical status I-III. Clonidine (15 µg) and methylprednisolone (40 mg) were compared as additives to 0.25% ropivacaine (5 mL) for SGB. After medical treatment for two weeks, patients in each of the two groups were given seven ultrasound guided SGBs on alternate days. Results: There was no significant difference between the two groups with respect to visual analogue scale score, edema, or overall patient satisfaction. After 1.5 months follow-up, however, the group that received methylprednisolone had better improvement in range of motion. No significant side effects were seen with either drug. Conclusions: The use of additives, both methylprednisolone and clonidine, is safe and effective for the SGB in CRPS. The significantly better improvement in joint mobility with methylprednisolone suggests that it should be considered promising as an additive to local anaesthetics when joint mobility is the concern.

Comparative evaluation of the analgesic efficacy of ultrasound-guided erector spinae plane block versus intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery: A prospective randomized pilot study.

OBJECTIVES: Existing research on erector spinae plane block and intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery is limited. METHODS: In this prospective, randomized study, 60 patients aged between 18 and 60 years were randomized into two groups (erector spinae plane block and intrathecal morphine). In the erector spinae plane block group, ultrasound-guided erector spinae plane block was performed, following which a mixture of 20 mL of 0.375% ropivacaine and 0.5 mcg/kg of clonidine was injected. In the intrathecal morphine group, 150 mcg preservative-free morphine with 2 mL of normal saline was administered intrathecally. The primary outcome was to evaluate the perioperative opioid consumption in the first 24 h. The secondary outcomes were to evaluate hemodynamic response to surgical stimulus, visual analogue scale score, time to first analgesic requirement, postoperative nausea and vomiting, postoperative opioid consumption, urethral irritation, and incidence of drug-related adverse effects. RESULTS: Total perioperative opioid consumption in the erector spinae plane block group was 355.0 (265.0, 485.0) µg and 240.0 (145.0, 370.0) µg in the intrathecal morphine group (P = 0.09). However, the patients in the erector spinae plane block group had significantly greater postoperative fentanyl consumption (235.0 [120.0, 345.0] µg) compared with those in the intrathecal morphine group (105.0 [30.0, 225.0] µg). There were no statistically significant differences noted for intraoperative opioid consumption, postoperative visual analogue scale score, time to first analgesic request, postoperative nausea and vomiting, and catheter irritation between the two groups. CONCLUSIONS: Although no statistically significant difference in intraoperative opioid consumption was seen between the erector spinae plane block and intrathecal morphine groups, postoperative opioid consumption was significantly higher in the erector spinae plane block group than in the intrathecal morphine group in patients undergoing percutaneous nephrolithotomy surgery.

Transforaminal Epidural Injection of Local Anesthetic and Dorsal Root Ganglion Pulsed Radiofrequency Treatment in Lumbar Radicular Pain: A Randomized, Triple-Blind, Active-Control Trial.

BACKGROUND: Lumbar radicular pain (LRP) results from inflammation and irritation of lumbar spinal nerves and the dorsal root ganglion (DRG). METHODS: Our study is a prospective, triple-blind, randomized, activecontrol trial (CTRI/2016/02/006666) comparing transforaminal epidural local anesthetic (LA) injection and pulsed radiofrequency treatment of DRG in patients with chronic LRP. Patients with LRP after failed conservative management for >3 months received selective diagnostic nerve root block with 1 mL 2% lidocaine. Fifty patients showing positive responses were divided into groups of 25 each. The LA group received transforaminal epidural injection of 1 mL 0.5% bupivacaine. The lumbar pulsed radiofrequency (LPRF) group received transforaminal epidural injection of 1 mL 0.5% bupivacaine with 3 cycles of pulsed radiofrequency of the DRG for 180 seconds RESULTS: Both groups were compared by observing pain intensity on a 0- to 100-point VAS and improvement in functional status by the Oswestry Disability Index (ODI version 2.0) at 2 weeks and 1, 2, 3, and 6 months. All baseline variables were comparable between the 2 groups. Statistically significant reduction in both outcomes was seen in the LPRF group compared to the LA group from 2 weeks to 6 months. One hundred percent of patients in the LPRF group had a ≥20- point decrease in VAS and significant percentage reduction in ODI at all time intervals up to 6 months, whereas it was seen in 80% and 28% of patients in the LA group at 3 and 6 months, respectively. No complications were seen in any patients CONCLUSION: Pulsed radiofrequency of the DRG applied for longer duration results in long-term pain relief and improvement in the functional quality of life in patients with chronic LRP.

Safety and analgesic efficacy of intravenous dexmedetomidine in arthroscopic knee surgery.

CONTEXT: Dexmedetomidine, a highly selective alpha-2 agonist has been used as an adjuvant analgesic in vascular, bariatric, and thoracic surgery. We assessed the efficacy of intravenous dexmedetomidine as an analgesic adjunct to local anesthetic infiltration for control of postoperative pain in arthroscopic knee surgery. SETTINGS AND DESIGN: This was a randomized control study performed in a Tertiary Care Hospital. MATERIALS AND METHODS: Forty-five adult patients scheduled for anterior/posterior cruciate ligament reconstruction were randomized into three groups. Group B (bupivacaine group) received bupivacaine intraarticularly and normal saline by the intravenous route. Group D (dexmedetomidine group) received Intravenous dexmedetomidine and normal saline intraarticularly. Group BD (bupivacaine + dexmedetomidine group) received a combination of intravenous dexmedetomidine and intraarticular bupivacaine. Patient's cardiorespiratory parameters, time to first rescue, total rescue analgesic consumption in first 24 h, visual analog scale for pain were assessed. STATISTICAL ANALYSIS: The data were analyzed using analysis of variance and Chi-square test. RESULTS: The time to first request for rescue analgesia was significantly prolonged in Group D and Group BD patients (P < 0.05) compared to Group B. Total rescue analgesic consumption was least in Group BD. Group D and Group BD patients had lower heart rate and systolic and diastolic blood pressure values. CONCLUSION: Intravenous dexmedetomidine in combination with intraarticular bupivacaine decreased perioperative analgesic requirement in patients undergoing arthroscopic knee surgery. However, monitoring and vigilance are essential if dexmedetomidine is used as part of a multimodal analgesic regimen in view of its hemodynamic side effects.

Analgesic efficacy and safety of medical therapy alone vs combined medical therapy and extraoral glossopharyngeal nerve block in glossopharyngeal neuralgia.

OBJECTIVE: The aim of this study is to compare medical therapy alone and medical therapy with add on extraoral glossopharyngeal nerve block in terms of analgesic efficacy and hemodynamic safety in patients with glossopharyngeal neuralgia (GPN). As GPN is a rare disease, our secondary targets were to review the demographic profile of the disease, clinical profile, and any associations with the disease. DESIGN: This was a randomized, prospective, active-controlled, parallel group study conducted from 2007 to 2009 to determine the safety and efficacy of extraoral glossopharyngeal nerve block in GPN and compare it with pharmacological intervention. After institutional ethics committee approval and patient's consent, GPN patients were randomly allocated into two groups. Group A (N = 15) received standard medical therapy (gabapentin 300 mg, tramadol 50 mg TDS, methylcobalamin 500 µgm PO) and group B (N = 15) patients received extraoral glossopharyngeal nerve block together with standard medical therapy. Patients were analyzed for analgesic outcome using numerical pain scale (NPS) and brief pain inventory (BPI) assessing both analgesic effect and degree of interference in quality of life (QOL) during 3-month follow-up. They were also evaluated for any significant hemodynamic alterations. RESULTS: Over the follow-up of 90 days, the mean NPS in group A decreased from 6 ± 2 to 3 ± 2 and in group B from 5 ± 1 to 2 ± 2. From the mean NPS scores, it can be interpreted that both the modalities were effective clinically in treating GPN. However, NPS scores were statistically similar by the end of 90 days. Improvement from baseline in BPI measurement of QOL (mood, interpersonal relationship, and emotion) was earlier in group B (1, 2, and 1 months, respectively) compared with group A (2, 3, and 2 months, respectively). However, there were no significant hemodynamic adverse outcomes after administration of the block. CONCLUSION: This study found that patients in both the groups had significantly lower pain intensities, improved pain relief, and reduced pain interference with QOL, which was especially evident on fourth visit (2 months) after the initiation of treatment regimen. Both were safe and well tolerated. The study advocates rational polypharmacy approach (oral and block) in difficult to treat painful conditions. Further controlled trials are warranted to further define the impact of such a combination therapy.

Advancement of epidural catheter from lumbar to thoracic space in children: Comparison between 18G and 23G catheters.

BACKGROUNDS AND OBJECTIVES: Lumbar-to-thoracic advancement of epidural catheter is a safe alternative to direct thoracic placement in children. In this prospective randomized study, success rate of advancement of two different types and gauges of catheter from lumbar-to-thoracic space were studied. MATERIALS AND METHODS: Forty ASA I and II children (up to 6 years) undergoing thoracic or upper-abdominal surgery were allocated to either Group I (18G catheter) or Group II (23G catheter). After induction of general anesthesia a pre-determined length of catheter was inserted. Successful catheter placement was defined as the catheter tip within two segment of surgical incision in radio-contrast study. Intra-operative analgesia was provided by epidural bupivacaine and intravenous morphine. Post-operative analgesia was provided with epidural infusion of 0.1% bupivacaine+1mcg/ml fentanyl. OBSERVATIONS AND RESULTS: Catheter advancement was successful in 3 cases in Group I and 2 cases in Group II. Five different types of catheter positions were found on X-ray. Negative correlation was found between age and catheter advancement [significance (2-tailed) =0.03]. However, satisfactory post-operative analgesia was obtained in 35 cases. Positive correlation was found between infusion rate, the number of segment of gap between desired level and the level reached [significance (2-tailed) =0.00]. 23G catheter use was associated with more technical complications. CONCLUSION: Advancement of epidural catheter from lumbar to thoracic level was successful in only 10-15% cases but satisfactory analgesia could be provided by increasing the infusion rates.

Dexamethasone before total laparoscopic hysterectomy: a randomized controlled dose-response study.

PURPOSE: A prospective, randomized, double blind, placebo-controlled study was undertaken to evaluate the efficacy of a single preoperative dose of dexamethasone, in different dosages, in providing postoperative analgesia in patients undergoing total laparoscopic hysterectomy (TLH). METHOD: The study included 55 patients randomly divided into three groups. Patients in Groups P, D4, and D8 received saline, 4, and 8 mg dexamethasone, respectively, intravenously, 2 h before induction. RESULTS: The time to first analgesic requirement was significantly delayed in patients in the D8 group compared with the D4 group (P = 0.01) and placebo (P = 0.01). Total postoperative fentanyl consumption was significantly less in patients in the D8 group compared with the D4 group (P = 0.01) and placebo (P = 0.01). Use of 8 mg dexamethasone resulted in a 99.3 mcg decrease in total 24-h fentanyl consumption. Postoperative nausea and vomiting (PONV) was significantly less in the D8 group with a complete response rate (no emetic episodes and no rescue medication for 24 h) of 36.8% compared with the placebo group in which all the patients had PONV. No adverse effects were observed in any group. CONCLUSION: Dexamethasone at a dose of 8 mg given intravenously 2 h before induction, delays patient request for analgesia and reduces total fentanyl consumption and PONV in patients undergoing TLH.

Evaluation of single-stage adjustable strabismus surgery under conscious sedation.

PURPOSE: To evaluate the feasibility and stability of ocular alignment after single-stage adjustable strabismus surgery (SSASS) performed under topical anesthesia. MATERIALS AND METHODS: Forty-five patients of concomitant exodeviations were randomized into three groups of 15 cases each and were operated with three different techniques: Group I - conventional surgery, Group II - two-stage adjustable suture technique with suture adjustment performed 6h postoperatively and Group III- SSASS under topical anesthesia and intravenous conscious sedation with midazolam and fentanyl. Intraoperative suture adjustment was done by giving a cross target to the patient on the ceiling at the end of the procedure. Surgical results were compared among the three groups at three months follow-up. Intraoperative hemodynamic parameters and patients' experience of the surgery (by questionnaire) were also compared. RESULTS: Mean preoperative deviation for distance in Groups I, II, III was -41.67 prism diopter (pd) +/-9.0, -38.93 pd +/-11.05 and -41.87 pd +/-8.91 ( P =0.6) respectively. At three months, mean correction achieved for distance was +31.87 pd +/-11.71, +35.47 pd +/-10.86 and +42.80 pd +/-10.71 respectively which was significantly different between Group III and Group I ( P =0.03). Intraoperatively all hemodynamic parameters remained stable and comparable ( P =0. 5) in all groups. Intraoperative pain ( P < 0.001) and time taken for surgery ( P < 0.001) was more in the SSASS group. Amount of exodrift was 10-12 pd, comparable in all three groups ( P = 0.5). CONCLUSIONS: SSASS, performed under topical anesthesia, is safe and has better outcomes than conventional recession-resection surgery for concomitant exodeviation. An overcorrection of about 10-12 pd is recommended to check the exodrift and achieve stable alignment.

Ambulatory total extraperitoneal inguinal hernia repair: feasibility and impact on quality of life.

BACKGROUND AND OBJECTIVES: Feasibility of ambulatory laparoscopic inguinal hernia repair in developing countries is not known due to lack of dedicated outpatient centers. This study prospectively evaluated the feasibility of outpatient discharge after laparoscopic total extraperitoneal inguinal hernia repair done in combination with in-hospital services and its impact on quality of life. METHODS: Forty patients were studied who had uncomplicated inguinal hernias and fulfilled the selection criteria. Quality of life was evaluated by using the SF-12 questionnaire. RESULTS: Ninety percent of patients could be discharged as outpatients. Four patients required admission. No major complications or readmissions occurred. Physical components of quality of life deteriorated in the immediate postoperative period but improved to above preoperative levels within one month. A transient deterioration in subgroups of the mental health component was observed, which recovered to normal in less than a week. There was no significant alteration in the emotional component. There has been no recurrence at a median follow-up of 25 months. CONCLUSION: It was feasible to safely perform outpatient TEP in combination with routine in-hospital services without increasing complications or causing any adverse impact on quality of life. This was possible subject to adherence to proper selection and discharge criteria.