Evaluation of Fastrach Laryngeal Mask Airway as an Alternative to Fiberoptic Bronchoscope to Manage Difficult Airway: A Comparative Study.

INTRODUCTION: Awake intubation via Fiberoptic Bronchoscope (FB) is the gold standard for management of difficult airway but patients had to face problems like oxygen desaturation, tachycardia, hypertension and anxiety due to awake state. This study was conducted to assess feasibility of Fastrach Laryngeal Mask Airway (FLMA) to manage difficult airway as a conduit for intubation as well as for ventilation. MATERIALS AND METHODS: After ethical approval and informed consent, 60 patients with difficult airway were randomly enrolled in FB group and FLMA group. In FB group, patients were sedated with midazolam/fentanyl. Airway anaesthetization of oropharynx was done with xylocaine spray and viscous and larynx and trachea by superior laryngeal nerve block and transtracheal block respectively. In FLMA group, initially patients were induced with propofol for FLMA insertion then succinylcholine was given for Tracheal Intubation (TI). The first TI attempt was done blindly via the FLMA and all subsequent attempts were performed with fiberoptic guidance. Haemodynamic monitoring was done during induction, intubation, immediately post insertion and there after at five minutes interval for 30 minutes. RESULTS: All patients in the FLMA group were successfully ventilated (100%). In both the groups 28 (93.33%) patients were successfully intubated. However, first/second/third attempt intubation rate in FLMA vs FB group was 15 (50%) vs 13 (43.3%), 8 (26.66%) vs 10 (33.33%) and 5 (16.66%) in both groups respectively. Patients in the FLMA group were more satisfied with their method of TI and had lesser complications (p<0.05). CONCLUSION: So the FLMA may be a better technique for management of patients with difficult airways.

Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief.

INTRODUCTION: Postoperative pain after thoracotomy is being considered one of the most severe pain and if not treated well, can result in various respiratory and other complications. AIM: Present study was conducted with the aim to compare continuous thoracic epidural infusion with continuous paravertebral infusion for postoperative pain using Visual Analogue Scale (VAS) score and four point observer ranking. The secondary outcomes measured were pulmonary functions and any complication like hypotension, bradycardia, nausea, vomiting, urinary retention and neurological complications if any. MATERIALS AND METHODS: Sixty patients of age group 18-60 years posted for anterolateral thoracotomy surgery for lung resection were randomised either to epidural or paravertebral group in this randomised prospective double blind study. In Epidural group 7.5ml bolus of 0.125% Bupivacaine with 50µg Fentanyl and in Paravertebral group 15ml bolus of 0.125% Bupivacaine with 50µg Fentanyl was given 30 minutes before the anticipated end of surgery. Bolus dose was followed by infusion of 0.125% Bupivacaine with 2µg/ml Fentanyl at the rate of 5 ml/hr in both groups. Parameters noted were Mean Arterial Pressure (MAP), Heart Rate (HR), Oxygen Saturation (SpO2), Arterial Blood Gas (PaCO2, P/F ratio), Visual Analogue Scale (VAS) and Four Point Observer Ranking Scale (FPORS) for pain, number of sensory segments blocked (by checking for pinprick sensation), requirement of infusion top ups and rescue analgesia (Tramadol), pre and postoperative pulmonary function test {(Forced Expiratory Volume (FEV)1, Forced Vital Capacity (FVC), FEV1/FVC, Peak Expiratory Flow Rate (PEFR)} and complications from start of infusion till 24 hours in the postoperative period. RESULTS: Both the techniques were effective in relieving pain but pain relief was significantly better with epidural. Postoperatively, HR, SpO2, P/F ratio and PaCO2 were comparable between group E and P. There was significant decline in FeV1, FVC, FeV1/FVC and PEFR in postoperative period as compared to preoperative value in both the groups. Hypotension and bradycardia were more in group E. CONCLUSION: Both the techniques, continuous thoracic epidural block and continuous thoracic paravertebral block were effective for post-thoracotomy pain relief; however, epidural block provides better pain relief. The incidence of sympatholytic complications was more in epidural group. The effect on respiratory mechanics was equivalent. Hence, paravertebral block can be used in post thoracotomy pain relief in those patients where thoracic epidural is contraindicated.

Transdermal Buprenorphine Patches for Postoperative Pain Control in Abdominal Surgery.

INTRODUCTION: Buprenorphine is a semi-synthetic derivative of thebaine; its low concentration is sufficient to provide effective pain relief. AIM: To evaluate the efficacy of transdermal buprenorphine patch in postoperative pain management. MATERIALS AND METHODS: After ethical approval and taking informed consent from the patients, they were randomized into three groups (n=30 in each group) using a computer generated random number table. Group A: placebo patch; Group B: buprenorphine (10mg) patch and Group C: buprenorphine (20mg) patch. Haemodynamic and analgesic effects were compared by using analysis of variance (ANOVA) followed by Turkey's post hoc test. The proportion of side effects was compared using the Chi-square test. RESULTS: Haemodynamic changes were not statistically different in all the three groups A, B and C, whereas at the end of surgery VAS score of Group A subjects was significantly higher (4.93±0.98) as compared to Group B (1.73±0.64) and Group C (1.40±0.50). On 2(nd) postoperative day, no pain was reported by the Group C patients and on 4(th) day after surgery, no pain was reported by Group B patients. CONCLUSION: The transdermal buprenorphine patch (20mg) was effective in attenuating postoperative pain, maintaining haemodynamic stability requiring no rescue analgesia, with fewer postoperative rescue analgesic requirements in low dose of buprenorphine patch (10mg) group.

Evaluation of the effect of magnesium sulphate vs. clonidine as adjunct to epidural bupivacaine.

For treatment of intra and postoperative pain, no drug has yet been identified that specifically inhibits nociception without associated side effects. Magnesium has antinociceptive effects in animal and human models of pain. The current prospective randomised double-blind study was undertaken to establish the effect of addition of magnesium or clonidine, as adjuvant, to epidural bupivacaine in lower abdominal and lower limb surgeries. A total of 90 American Society of Anesthesiology (ASA) grade I and II patients undergoing lower abdominal and lower limb surgeries were enrolled to receive either magnesium sulphate (Group B) or clonidine (Group C) along with epidural bupivacaine for surgical anaesthesia. All patients received 19 ml of epidural bupivacaine 0.5% along with 50 mg magnesium in group B, 150 mcg clonidine in Group C, whereas in control group (Group A), patients received same volume of normal saline. Onset time, heart rate, blood pressure, duration of analgesia, pain assessment by visual analogue score (VAS) and adverse effects were recorded. Onset of anaesthesia was rapid in magnesium group (Group B). In group C there was prolongation of duration of anaesthesia and sedation with lower VAS score, but the incidence of shivering was higher. The groups were similar with respect to haemodynamic variables, nausea and vomiting. The current study establishes magnesium sulphate as a predictable and safe adjunct to epidural bupivacaine for rapid onset of anaesthesia and clonidine for prolonged duration of anaesthesia with sedation.