The predictors of hyperglycemia and its effects on neurological outcome in the patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping: A prospective observational study.

Background: Following intracranial aneurysm rupture, 70-90% of patients have hyperglycemia as a stressful response. Uncontrolled hyperglycemia is deleterious if not controlled well. The objectives of the study were to assess the prevalence, risk factors of hyperglycemia, and its effect on outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients who underwent aneurysmal clipping. Methods: Following intracranial aneurysm rupture, 70-90% of patients have hyperglycemia as a stressful response. Uncontrolled hyperglycemia is deleterious if not controlled well. The objectives of the study were to assess the prevalence, risk factors of hyperglycemia, and its effect on outcome in aSAH patients who underwent aneurysmal clipping. Results: At admission, the prevalence of hyperglycemia and severe hyperglycemia was 31.8% and 6.8%, respectively. Perioperative hyperglycemia and severe hyperglycemia were seen in 75.7% and 27%, respectively. History of diabetes mellitus (DM), higher admission random blood sugar, and higher admission mean blood pressure were predictors of perioperative hyperglycemia (P- 0.046, 0.00, and 0.004, respectively) and severe hyperglycemia (P- 0.048, 0.00, and 0.031). In addition, female sex, prolonged duration of anesthesia, and surgery were also found to be the predictors of hyperglycemia (P- 0.025, 0.07, and 0.012). Increased ventilator, intensive care unit, and hospital days were associated with perioperative hyperglycemia and severe hyperglycemia, respectively (P ≤ 0.006/0.00, P ≤ 0.007/0.00, and P ≤ 0.038/0.00). Poor Glasgow Outcome Score at 1 and 3 months after discharge was associated with admission and perioperative hyperglycemia ([P ≤ 0.000/0.000 and P ≤ 0.000/0.000], respectively). However, no association was seen between mortality and hyperglycemia or severe hyperglycemia. Conclusion: A higher prevalence of hyperglycemia is present in aSAH patients. A higher incidence of perioperative hyperglycemia is associated with poor neurological outcomes. Hence, the identification of risk factors and meticulous perioperative control of hyperglycemia will help in preventing poor neurological outcomes.

Evaluation of the changes in middle cerebral artery flow velocity related to different positions of patients during posterior fossa surgery.

Background: This is a prospective observational study to evaluate the changes in middle cerebral artery flow velocities and cerebral perfusion pressure in the various positions used for posterior cranial fossa surgery and to correlate these changes with postoperative recovery characteristics and complications. Methods: Sixty patients were included in the study - 33 patients with CPA tumors were placed in the supine with head tilt position and the rest 27 with tumors in other locations of posterior fossa were placed in the prone position. The primary aim was to study the changes in middle cerebral artery blood flow velocity related to various positions of the patients used during posterior fossa surgery. The secondary aim was to compare the changes in pulsatility index, resistance index, and effective cerebral perfusion pressure in different position and to correlate these findings with postoperative recovery and the complications associated with these positions. Results: The systolic and mean flow velocities were higher in the supine with head tilt group than the prone group after positioning and post repositioning, but these values were within normal limits, and the changes with positioning from baseline were comparable between the groups. Furthermore, these changes did not affect the effective cerebral perfusion pressure or the outcomes of the patients. Conclusion: The current results do not determine whether the supine with head tilt position is better than the prone position during posterior fossa surgery.

Efficacy of serratus anterior plane block versus thoracic paravertebral block for postoperative analgesia after breast cancer surgery - a randomized trial

Abstract Background Breast cancer surgery is associated with considerable acute post-surgical pain and restricted mobility. Various regional and neuraxial anesthesia techniques have been used to alleviate post-mastectomy pain. Ultrasound-guided serratus anterior plane block (SAPB) has been considered a simple and safe technique. This randomized control study was performed to compare the efficacy of SAPB with the thoracic paravertebral block (TPVB) for postoperative analgesia after breast cancer surgery. Methods A total of 40 adult ASA physical status I - II female patients undergoing radical mastectomy were randomly allocated into two groups to receive either ultrasound-guided TPVB or SAPB with 0.4 mL.kg-1 0.5% ropivacaine, 30 min before surgery. All patients received standardized general anesthesia for surgery. Injection diclofenac and tramadol were used for postoperative rescue analgesia. The time to first rescue analgesia, total analgesic consumption in the first 24 hours, postoperative pain scores, and any adverse effects were recorded. Results The time to first rescue analgesia was significantly longer in the SAPB group (255.3 ± 47.8 min) as compared with the TPVB group (146.8 ± 30.4 min) (p< 0.001). Total diclofenac consumption in 24 hours was also less in the SAPB group (138.8 ± 44.0 mg vs 210.0 ± 39.2 mg in SAPB and TPVB group respectively, p< 0.001). Postoperative pain scores were significantly lower in the SAPB group as compared with TPVB group (p< 0.05). The incidence of PONV was also less in the SAPB group (p= 0.028). No block-related adverse effects were reported. Conclusion We found that the serratus anterior plane block was more effective than the thoracic paravertebral block for postoperative analgesia after breast cancer surgery.

Impact of Stellate Ganglion Block in the Management of Cerebral Vasospasm: A Prospective Interventional Study.

Background: Stellate ganglion block (SGB) causes blockage of sympathetic nerve activity, which may lead to intracerebral vessel dilatation and relieve cerebral vasospasm in patients of aneurysmal subarachnoid hemorrhage (aSAH). Objective: The aim of this study was to evaluate the efficacy and safety of SGB to relieve cerebral vasospasm on clinicoradiological parameters. Materials and Methods: We prospectively included 20 patients with clinical and angiographic evidence of vasospasm post aneurysmal clipping. Cerebral blood flow velocity and Lindegaard ratio were assessed using transcranial Doppler (TCD). Location of vasospasm, vessel diameter, vasospasm severity, parenchymal filling time, and venous sinus filling time were assessed on digital subtraction angiography (DSA). Patients received ultrasound-guided SGB with 10 mL of 0.5% bupivacaine on the ipsilateral side of the vasospasm. After 30 minutes, the neurological status, TCD, and DSA parameters were reevaluated. Results: After SGB, there was statistically significant reduction in the middle cerebral artery (MCA) peak systolic velocity (P = 0.005), mean flow velocity (P = 0.025), and Lindegaard ratio (P = 0.022) on TCD. We observed significant dilatation in the mean vessel diameter measured at the mid-M1 segment of MCA (P = 0.003) and mid-A1 segment of ACA (P = 0.002) on DSA. The mean parenchymal filling time and mean venous sinus filling time decreased nonsignificantly after SGB (P = 0.163/0.104). Neurological improvement was observed in five (25%) patients. Conclusion: SGB has positive clinicoradiological influence in the management of cerebral vasospasm of large vessels. However, its effect on cerebral microvasculature is limited and needs a larger database for further analysis.

Efficacy of serratus anterior plane block versus thoracic paravertebral block for postoperative analgesia after breast cancer surgery - a randomized trial.

BACKGROUND: Breast cancer surgery is associated with considerable acute post-surgical pain and restricted mobility. Various regional and neuraxial anesthesia techniques have been used to alleviate post-mastectomy pain. Ultrasound-guided serratus anterior plane block (SAPB) has been considered a simple and safe technique. This randomized control study was performed to compare the efficacy of SAPB with the thoracic paravertebral block (TPVB) for postoperative analgesia after breast cancer surgery. METHODS: A total of 40 adult ASA physical status I - II female patients undergoing radical mastectomy were randomly allocated into two groups to receive either ultrasound-guided TPVB or SAPB with 0.4 mL.kg-1 0.5% ropivacaine, 30 min before surgery. All patients received standardized general anesthesia for surgery. Injection diclofenac and tramadol were used for postoperative rescue analgesia. The time to first rescue analgesia, total analgesic consumption in the first 24 hours, postoperative pain scores, and any adverse effects were recorded. RESULTS: The time to first rescue analgesia was significantly longer in the SAPB group (255.3 ±â€¯47.8 min) as compared with the TPVB group (146.8 ±â€¯30.4 min) (p < 0.001). Total diclofenac consumption in 24 hours was also less in the SAPB group (138.8 ± 44.0 mg vs 210.0 ± 39.2 mg in SAPB and TPVB group respectively, p < 0.001). Postoperative pain scores were significantly lower in the SAPB group as compared with TPVB group (p < 0.05). The incidence of PONV was also less in the SAPB group (p = 0.028). No block-related adverse effects were reported. CONCLUSION: We found that the serratus anterior plane block was more effective than the thoracic paravertebral block for postoperative analgesia after breast cancer surgery.

Effect of diffusion of anaesthetic gases on fibre-optic view change of laryngeal mask airway and post-operative laryngo-pharyngeal morbidity in children - A randomised controlled trial.

BACKGROUND AND AIMS: The diffusion of nitrous oxide (N2O) into the air-filled cuff of the classic laryngeal mask airway (LMA) may lead to an increase in cuff pressure (CP) and displacement of LMA affecting its performance. This study was conducted to evaluate the change in optimal position of LMA by fibre-optic bronchoscope, the changes in cuff pressure and oropharyngeal leak pressure (OLP), and post-operative laryngo-pharyngeal morbidity during N2O-oxygen (O2) anaesthesia in children. METHODS: After ethics committee approval and written informed consent, 84 children, aged 2 to 8 years undergoing lower abdominal surgery using LMA were included. Anaesthesia was induced with sevoflurane and maintained with either 33% O2 in air (Group 1) or with 33% O2 in 67% N2O (Group 2) along with sevoflurane. The position of LMA using fibre-optic bronchoscope, CP and OLP were recorded at 30, 60 and 90 minutes and at the end of surgery. The incidence of post-operative sore throat, hoarseness of voice and dysphagia was assessed for 24 hours. RESULTS: A mild (Grade 1) change in fibre-optic position of LMA was observed in 6 out of 42 children maintained with N2O-O2 anaesthesia. The cuff pressure was higher than baseline in group 2 at all three time points with the maximum at 90 minutes (93.23 ± 14.86 cm H2O vs. 39.78 ± 7.75 cm H2O; P < 0.05). The OLP was comparable between the groups during the initial 60 minutes and then increased in group 2. The incidence of post-operative sore throat was significantly higher in group 2 (P = 0.008). CONCLUSION: The diffusion of anaesthetic gases into the air-filled cuff does not change the fibre-optic position of the LMA significantly but increases the cuff pressure and incidence of post-operative laryngo-pharyngeal complications in children.

Comparison of Ketofol (Combination of Ketamine and Propofol) and Propofol Anesthesia in Aneurysmal Clipping Surgery: A Prospective Randomized Control Trial.

BACKGROUND: The maintenance of hemodynamic stability is of pivotal importance in aneurysm surgeries. While administering anesthesia in these patients, the fluctuations in blood pressure may directly affect transmural pressure, thereby precipitating rupture of aneurysm and various other associated complications. We aimed to compare the effects of ketofol with propofol alone when used as an induction and maintenance anesthetic agent during surgical clipping of intracranial aneurysms. MATERIALS AND METHODS: Forty adult, good-grade aneurysmal subarachnoid hemorrhage patients posted for aneurysm neck clipping were included in the study. The patients were randomized into two groups. One group received a combination of ketamine and propofol (1:5 ratio) and the other group received propofol for induction and maintenance of anesthesia. Intraoperative hemodynamic stability, intraventricular pressure, and quality of brain relaxation were studied in both the groups. RESULTS: The patients were comparable with respect to demographic profile, Hunt and Hess grade, world federation of neurological surgeons (WFNS) grade, Fisher grade, duration of anesthesia, duration of surgery, optic nerve sheath diameter, and baseline hemoglobin. Intraoperative hemodynamics were better maintained in the ketofol group during induction, with only 15% of patients having >20% fall in mean arterial pressure (from baseline) intraoperatively, compared to 45% of patients receiving propofol alone (P = 0.038). The mean intraventricular pressure values in both the groups were in the normal range and the quality of brain relaxation was similar, with no significant difference (P > 0.05). CONCLUSION: Ketofol combination (1:5) as compared to propofol alone provides better hemodynamic stability on induction as well as maintenance anesthesia without causing an increase in intracranial pressure. Effect of ketofol on cerebral oxygenation and quality of emergence need to be evaluated further by larger multicentric, randomized control trials.

Comparison of Propofol and Sevoflurane on Cerebral Oxygenation Using Juglar Venous Oximetery (SjVo2) in Patients Undergoing Surgery for Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) induces major insult to the normal cerebral physiology. The anesthetic agents may infrequently produce deleterious effects and further aggravate damage to the injured brain. This study was conducted to evaluate the effects of propofol and sevoflurane on cerebral oxygenation, brain relaxation, systemic hemodynamic parameters and levels of interleukin-6 (IL-6) in patients with severe TBI undergoing decompressive craniectomy. METHODS: A prospective randomized comparative study was conducted on 42 patients undergoing surgery for severe TBI. Patients were randomized into two groups, Group P received propofol and Group S received sevoflurane for maintenance of anesthesia. All patients were induced with fentanyl, propofol, and vecuronium. The effect of these agents on cerebral oxygenation was assessed by jugular venous oxygen saturation (SjVO2). Hemodynamic changes and quality of intraoperative brain relaxation were also assessed. The serum levels of IL-6 were quantitated using enzyme-linked immunosorbent assay technique. RESULTS: SjVO2 values were comparable and mean arterial pressure (MAP) was found to be significantly lower in Group P as compared to those in Group S (P < 0.05). Brain relaxation scores were comparable between the groups. The level of IL-6 decreased significantly at the end of surgery compared to baseline in patients receiving sevoflurane (P = 0.040). CONCLUSIONS: Cerebral oxygenation measured by SjVO2 was comparable when anesthesia was maintained with propofol or sevoflurane. However, significant reduction in MAP by propofol needs attention in patients with severe TBI. The decrease in IL-6 level reflects anti-inflammatory effect and probable neuroprotective potential of propofol and sevoflurane.

Parents' perception and factors affecting compliance with preoperative fasting instructions in children undergoing day care surgery: A prospective observational study.

BACKGROUND AND AIMS: Fasting guidelines have been recommended in the paediatric population to minimise the risk of pulmonary aspiration. The present study was planned to assess the compliance with fasting instructions in children undergoing ambulatory surgery and identify the factors affecting it. METHODS: A total of 1,050 ASA I and II children aged 1-12 years, scheduled for day care surgery were enrolled. Parents of these children were given a questionnaire with specific questions like fasting instructions, source of instructions, actual fasting times and reasons for not following instructions. RESULTS: Only 90 (8.5%) parents followed fasting instructions as advised. Of the 960 non-compliant patients, 31 (2.9) inadequately fasted while 929 (88.4%) fasted more than advised. While only 5.2% mentioned aspiration, 25% cited vomiting as the reason for fasting. Younger parents (OR = 0.853, 95% CI-0.796 to 0.915), fasting instructions in writing (OR = 10.808, 95% CI-1.459 to 80.059) and separate instruction for solids and liquids (OR = 6.016, 95% CI- 3.663 to 9.883) were found to affect compliance with fasting instructions. CONCLUSION: To avoid risks of prolonged or inadequate fasting in day care surgical patients, good coordination between the anaesthetist and the surgeon and an updated knowledge about the preoperative fasting instructions among the health-care providers is essential. Separate written fasting instructions for liquids and solids should be given to the parents according to their order in the operating list to ensure better compliance with fasting instructions.

Evaluation of Arterial to End-tidal Carbon Dioxide Pressure Differences during Laparoscopic Renal Surgery in the Lateral Decubitus Position.

BACKGROUND: End-tidal carbon dioxide (PEtCO2) is a noninvasive reliable technique to measure arterial partial pressure of carbon dioxide (PaCO2) in the body under general anesthesia. However, gradient between PaCO2 and PEtCO2 (P[a-Et] CO2) is influenced by many factors. AIMS: In the present study, we evaluated the changes in P (a-Et) CO2 for laparoscopic donor nephrectomy in lateral decubitus position (LDP). SETTINGS AND DESIGN: This was an observational, double-blinded, tertiary care center-based study. METHODS: Thirty-one American Society of Anesthesiologists Class I and Class II patients of either sex undergoing laparoscopic donor nephrectomy in LDP under general anesthesia were included. An arterial cannula was inserted, PaCO2 was measured at eight predesignated time intervals, and PEtCO2 was also noted at the corresponding time period. STATISTICAL ANALYSIS: Data were analyzed using a two-way analysis of variance for repeated measurements using one dependent variable and one within-subject factor (time). Quantitative data were presented as mean ± standard deviation or median and interquartile range, as appropriate. RESULTS: The mean P (a-Et) CO2 gradient was 5.67 ± 1.36 mmHg 10 min after induction of anesthesia in the supine position (T1a). Ten minutes after LDP, P (a-Et) CO2 gradient was 7.38 ± 1.45 mmHg (T1b) and was higher than T1a. The P (a-Et) CO2 values 10 min after release of pneumoperitoneum and 10 min after making the patient supine were significantly higher than the T1a value. The highest value of P (a-Et) CO2 gradient was at 30 min after creation of pneumoperitoneum (T30), i.e., 9.99 ± 1.70 mmHg. Pearson's correlation coefficient showed that the degree of correlation varied considerably during surgery due to interindividual variability (R 2 T1a vs. T60 was 0.61 vs. 0.17). CONCLUSIONS: PEtCO2 does not reliably predict PaCO2 in healthy patients scheduled for laparoscopic renal surgery in LDP.

Radiofrequency Thermoablation of the Gasserian Ganglion Versus the Peripheral Branches of the Trigeminal Nerve for Treatment of Trigeminal Neuralgia: A Randomized, Control Trial.

BACKGROUND: Trigeminal neuralgia is the most painful condition of facial pain leading to impairment of routine activities. Although radiofrequency thermoablation (RFT) of the Gasserian ganglion is widely used for the treatment of idiopathic trigeminal neuralgia in patients having ineffective pain relief with medical therapy, the incidence of complications like hypoesthesia, neuroparalytic keratitis, and masticatory muscles weakness is high. Recent case reports have shown the effectiveness of RFT of the peripheral branches of the trigeminal nerve for relief of refractory chronic facial pain conditions including trigeminal neuralgia. OBJECTIVES: This study was conducted to compare the efficacy and safety of RFT of the peripheral branches of the trigeminal nerve with RFT of the Gasserian ganglion for the management of idiopathic trigeminal neuralgia. STUDY DESIGN: Prospective, randomized, observer-blinded, clinical trial. SETTING: Tertiary care hospital and medical education and research institute. METHODS: A total of 40 adult patients of idiopathic trigeminal neuralgia were randomly allocated into 2 groups. The control group received RFT of the Gasserian ganglion while the study group received RFT of the peripheral branches of trigeminal nerve. The procedures were performed in the operation room under all aseptic precautions with fluoroscopic guidance. Post-procedure, the patients were assessed for loss of sensation along the nerve distribution and the adequacy of pain relief on the Numerical Rating Scale (NRS). The patients were followed up for 3 month to assess the quality of pain relief by the NRS and the Barrow Neurological Institute (BNI) pain intensity scale. Improvement in pain was considered excellent if patients had complete pain relief without any medication, good if there was significant reduction in pain (> 50%) with or without medication, and poor if there was less than 50% reduction in pain with medications. Patients were also assessed for numbness and any other side effects. Patients' satisfaction with the procedure was recorded. RESULTS: Nineteen patients in the control group and 18 in study group had effective pain relief of up to 3 months. Their pain scores were comparable at all time intervals, though the number of patients receiving supplementary medications was more in study group at 2 months (P = 0.015). The patients showed overall satisfaction score of 8.5 (8-9) and 8 (7-9) in control and study groups respectively. The average procedure duration was 30 (30-38) minutes in the control group and 28 (25-40) minutes in the study group. Most of the patients in both groups had mild numbness after the procedure. One patient in the control group had lower eyelid swelling and another had mild weakness of the masseter muscle, which resolved few days later. No major complication was reported in the study group except for 1 patient who reported local ecchymosis. LIMITATIONS: The main limitation of the study is that the patients and the investigator performing the procedure were not blinded, though the person who assessed the patient during follow-up was blinded to the group assignment. Another limitation is that we could not follow up with the patients after 3 months due to time constraints. CONCLUSION: We found that radiofrequency thermoablation of the peripheral branches of the trigeminal nerve is an effective and safe procedure for the management of idiopathic trigeminal neuralgia. KEY WORDS: Idiopathic trigeminal neuralgia, radiofrequency thermoablation, Gasserian ganglion, peripheral nerve branches, pain, trigeminal nerve.

Pulsed Radiofrequency Ablation for the Treatment of Glossopharyngeal Neuralgia Secondary to Oropharyngeal Carcinoma.

BACKGROUND: The management of glossopharyngeal neuralgia due to oropharyngeal carcinoma is particularly difficult because of rich innervations of the area, erosive nature of neoplasm and dynamic pain evoked by the functional movements like swallowing and chewing. Few case reports have shown the efficacy of pulsed radiofrequency (PRF) treatment in primary and secondary glossopharyngeal neuralgia in non-cancer patients. However, the efficacy of PRF ablation of the glossopharyngeal nerve in oral cancer patients is not known. OBJECTIVES: This study was conducted to evaluate the efficacy and safety of PRF ablation of the glossopharyngeal nerve for the management of oropharyngeal cancer pain involving the base of the tongue, tonsillar fossa, and oropharynx. STUDY DESIGN: Prospective interventional clinical trial. SETTING: Tertiary care hospital and medical education and research institute. METHODS: A total of 25 adult patients suffering from oropharyngeal carcinoma, complaining of severe pain in the area mainly supplied by glossopharyngeal nerve, were included. The patients underwent fluoroscopy-guided PRF ablation of the glossopharyngeal nerve of the affected site 3 times at 42°C temperature for 120 seconds with 22-gauge, 10 cm long, 5 mm active tip radiofrequency needle. They were followed up for one year for pain relief, nausea-vomiting and sleep disturbances. The treatment was considered effective if there was 50% reduction in pain score at 2 weeks. RESULTS: There was significant reduction in the overall pain score including site specific pain, odynophagia and ear pain after radiofrequency ablation (P < 0.0001) in all the patients. This was associated with decreased opioid consumption (P < 0.001), lesser nausea/vomiting, and improved sleep. The treatment was effective in 23 out of 25 patients (92%) for more than 3 months. No major complication was observed in any patient. The average duration of effective pain relief was 5 to 9 months. LIMITATIONS: Patients having bilateral glossopharyngeal neuralgia or an advanced stage of oral cancer with large lymph nodes at the angle of mandible were not included. This study was a single-center observational clinical trial and further multi-center, randomized, controlled trails are needed to obtain higher level of evidence. CONCLUSION: Our results showed that PRF ablation can be used effectively and safely for the treatment of glossopharyngeal neuralgia secondary to oropharyngeal carcinoma. KEY WORDS: Glossopharyngeal neuralgia, ear pain, odynophagia, oral cancer pain, pulsed radiofrequency ablation, side effects.

Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthetic Agent in Scalp Block and Scalp Infiltration to Control Postcraniotomy Pain: A Double-Blind Randomized Trial.

CONTEXT: Scalp infiltration and scalp block are being used to manage postcraniotomy pain. Dexmedetomidine has been successfully used as an adjuvant in regional anesthesia. The study was intended to compare whether addition of dexmedetomidine prolonged the duration of analgesia as well as to compare the two techniques. AIMS: The primary objective was to assess whether addition of dexmedetomidine to bupivacaine prolonged the duration of analgesia. The secondary objective was to compare between scalp nerve block and scalp infiltration as techniques for pain relief. SETTINGS AND DESIGN: The randomized control study was conducted in a tertiary care center from November 2013 to October 2014. MATERIALS AND METHODS: A total of 150 American Society of Anesthesiologists Physical Status I-II patients, aged 18-70 years undergoing elective craniotomy were included. Patients were randomized into three groups of 50 patients, i.e., Group BI (bupivacaine infiltration), Group BDI (bupivacaine and dexmedetomidine infiltration), and Group BDNB (bupivacaine and dexmedetomidine scalp nerve block). Patient's pain score, pain-free interval, rescue analgesic requirement, and hemodynamic and respiratory parameters were noted for 48 h. Patients were followed up at 1 and 3 months to assess postcraniotomy pain. RESULTS: Pain-free period was significantly longer in Group BDNB than Groups BDI and BI (P < 0.0001) and pain control was better in dexmedetomidine containing groups than in bupivacaine group (BI) (P < 0.0001). The rescue analgesic requirement was significantly lower in Group BDNB and Group BDI compared to Group BI. CONCLUSION: The addition of dexmedetomidine (1 µg/kg) to bupivacaine prolonged the pain-free period. Scalp nerve block is a superior technique than scalp infiltration.

Analgesic efficacy of dexmedetomidine versus fentanyl as an adjunct to thoracic epidural in patients undergoing upper abdominal surgery: a randomized controlled trial

Background: This randomised, double-blind study was designed to assess the analgesic efficacy of dexmedetomidine as compared with fentanyl as an adjunct to local anaesthetic in thoracic epidural for upper abdominal surgeries. Methods: Forty adult patients of American Society of Anesthesiologists grade I­II undergoing upper abdominal surgery were randomly allocated into two groups to receive 50 µg fentanyl or 50 µg dexmedetomidine as an adjunct to 10 ml 0.125% bupivacaine via thoracic epidural. Anaesthesia was induced with morphine, propofol and vecuronium and maintained by isoflurane with 60% nitrous oxide in oxygen. In the postoperative period patient-controlled analgesic pumps were used to deliver similar types of mixtures via the epidural catheter. Patients were evaluated for rescue analgesic requirements, haemodynamic stability, postoperative pain, sedation and any adverse events. Results: The groups were comparable regarding intraoperative analgesic requirements, recovery times and postoperative pain scores. The total consumption of rescue analgesia was significantly less in the dexmedetomidine group as compared with the fentanyl group (p = 0.049). Two patients in the fentanyl group had vomiting and one had pruritus. None of the patients had bradycardia, hypotension, excessive sedation or respiratory depression. Patients receiving epidural dexmedetomidine were more satisfied with the technique than those receiving fentanyl (p < 0.001). Conclusion: It was concluded that the addition of dexmedetomidine with 0.125% bupivacaine in thoracic epidural provides effective perioperative analgesia with greater patient satisfaction compared with fentanyl

Effects of intraoperative liberal fluid therapy on postoperative nausea and vomiting in children-A randomized controlled trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most distressing complications following surgery. Supplemental perioperative fluid therapy might be an effective strategy to reduce PONV in children. OBJECTIVES: The study was conducted to evaluate the effects of intraoperative liberal fluid therapy with crystalloids on PONV in children. METHODS: In this randomized trial, a total of 150 children of 3-7 years undergoing lower abdominal and penile surgery under general anesthesia were randomly assigned into two groups. "Restricted group" received 10 mL kg-1 h-1 and "Liberal group" received 30 mL kg-1 h-1 infusion of Ringer's lactate solution intraoperatively. All patients received a caudal block and intravenous paracetamol for analgesia. No opioids and muscle relaxants were used. All episodes of nausea-vomiting and the requirement of rescue antiemetic were assessed during 24 hours postoperatively. RESULTS: The incidence of PONV was significantly less in the liberal group patients as compared to the restricted group; 33 (45.8%) patients in the restricted group had vomiting as compared to 20 (27.4%) patients in the liberal group (RR 0.59, 95% CI: 0.38-0.93, P=.021). The adjusted odds ratio of PONV for the liberal group vs restricted group was 2.24 (95% CI: 1.12-4.48, P=.022). The incidence of fluid intake during the first 6 postoperative hours was significantly higher in the restricted group patients; 60 (83%) children in the restricted group complained of thirst as compared to 12 (17%) children in the liberal group (RR 0.19, 95% CI: 0.18-0.33, P=.0001). The parents of the liberal group were more satisfied as compared to the restricted group (mean difference -0.9, 95% CI: -1.8, -0.1, P=.04). None of the children had any complication attributed to the liberal fluid therapy. CONCLUSION: Liberal intraoperative fluid therapy was found to be effective in reducing PONV in children undergoing lower abdominal surgery.

Steroid vs. Platelet-Rich Plasma in Ultrasound-Guided Sacroiliac Joint Injection for Chronic Low Back Pain.

BACKGROUND: Despite widespread use of steroids to treat sacroiliac joint (SIJ) pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain. OBJECTIVES: To assess the efficacy and safety of PRP compared with methylprednisolone in ultrasound-guided SIJ injection for low back pain. STUDY DESIGN: Prospective randomized open blinded end point (PROBE) study. METHODS: Forty patients with chronic low back pain diagnosed with SIJ pathology were randomly allocated into 2 groups. Group S received 1.5 mL of methylprednisolone (40 mg/mL) and 1.5 mL of 2% lidocaine with 0.5 mL of saline, while Group P received 3 mL of leukocyte-free PRP with 0.5 mL of calcium chloride into ultrasound-guided SIJ injection. Visual analog scale (VAS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, Short Form (SF-12) Health Survey scores, and complications (if any) were evaluated at 2 weeks, 4 weeks, 6 weeks, and 3 months. RESULTS: Intensity of pain was significantly lower in Group P at 6 weeks (median [interquartile range (IQR)] = 1 [1 to 1] vs. 3.5 [2 to 5]; P = 0.0004) and 3 months (Median [IQR] = 1 [1 to 3] vs. 5 [3 to 5]; P = 0.0002) as compared to Group S. The efficacy of steroid injection was reduced to only 25% at 3 months in Group S, while it was 90% in Group P. A strong association was observed in patients receiving PRP and showing a reduction of VAS ≥ 50% from baseline when other factors were controlled. The MODQ and SF-12 scores were improved initially for up to 4 weeks but deteriorated further at 3 months in Group S, while both the scores improved gradually for up to 3 months in Group P. CONCLUSION: The intra-articular PRP injection is an effective treatment modality in low back pain involving SIJ.

The Analgesic Efficacy of Dexmedetomidine as an Adjunct to Local Anesthetics in Supraclavicular Brachial Plexus Block: A Randomized Controlled Trial.

BACKGROUND: This study was designed to assess the effects of dexmedetomidine on the onset and duration of block and postoperative analgesia during supraclavicular brachial plexus block in patients undergoing upper limb surgeries. METHODS: Sixty adult patients undergoing upper limb and hand surgeries were randomly allocated into 2 groups. The control group received equal volumes of 0.75% ropivacaine and 2% lidocaine with adrenaline, whereas the dexmedetomidine (dexmed) group received 1 µg/kg dexmedetomidine along with equal volumes of 0.75% ropivacaine and 2% lidocaine with adrenaline. A total volume of 0.5 mL/kg was administered in ultrasound-guided supraclavicular brachial plexus block in both groups. Patients were observed for hemodynamic stability, onset and duration of sensory and motor blockade, duration of analgesia, postoperative pain, and adverse effects. RESULTS: The onset time of motor blockade was shortened and the duration of sensory, as well as motor, block was significantly prolonged in the dexmed group (P < 0.0001). The duration of postoperative analgesia was also longer in the dexmed group compared with the control group (median [interquartile range], 12 [10.5-13.5] hours and 17 [10.5-19.5] hours in control and dexmed group, respectively [95% confidence interval, -5 {-5, -4}, P < 0.0001]). The requirement for rescue analgesic during the 24-hour postoperative period was less in the dexmed group (P < 0.0001). Postoperative pain scores were comparable among groups except at 8 and 10 hours, when pain scores were lower in the dexmed group. Patients receiving dexmedetomidine were more sedated for 2 hours than the control group patients (P < 0.0001). No episode of bradycardia, hypotension, respiratory depression, or dizziness was reported. CONCLUSIONS: We conclude that the addition of dexmedetomidine to ropivacaine-lidocaine prolonged the duration of supraclavicular brachial plexus block and improved postoperative analgesia without significant adverse effects in patients undergoing upper limb surgeries.