The Efficacy and Safety of Spinal Anesthesia With Hyperbaric Ropivacaine 0.75% and Bupivacaine 0.5% in Patients Undergoing Infra-Umbilical Surgeries: A Randomized, Double-Blind Study.

BACKGROUND: Spinal anesthesia utilizing hyperbaric 0.75% ropivacaine has been gaining clinical acceptance recently. It is a pure S-enantiomer of bupivacaine, which is expected to have a better clinical profile, but the studies for the same are yet limited. We aimed to compare the efficacy and safety of these two drugs. METHODS: Sixty patients, aged 18 to 60 years of either sex, classified as American Society of Anesthesiologists class I and II, who were undergoing elective infra-umbilical surgery, were randomly assigned to receive either 3 mL of 0.5% bupivacaine heavy or 3 mL of 0.75% ropivacaine heavy intrathecally. Efficacy parameters, including the onset and duration of sensory and motor block, time to rescue analgesia, hemodynamics, and safety in terms of complications, were recorded. We compared the data for statistical significance, considering a p-value of less than 0.05 as significant. RESULTS: Ropivacaine exhibited a slower onset for both sensory (153.90 ± 6.53 versus 92.46 ± 12.16 seconds; p < 0.001) and motor blockades (301 ± 6.62 versus 239.96 ± 6.27 seconds; p < 0.001). Two-segment sensory and motor blockade regression were faster with ropivacaine compared to bupivacaine (p < 0.001). However, the mean duration of sensory blockade for ropivacaine compared to that for bupivacaine (219.29 ± 15.14 versus 227.31 ± 17.20 minutes) and the requirement for rescue analgesia were not statistically different (p > 0.05). Ropivacaine also caused fewer side effects on a percentage scale. CONCLUSION: In patients undergoing infra-umbilical surgery, hyperbaric ropivacaine at an equipotent dose (0.75%) proved to be a comparable and safer alternative to hyperbaric bupivacaine (0.5%). Furthermore, it had better motor-recovery profiles.

A randomized trial to compare the analgesic effect of pecto-intercostal fascial plane block with erector spinae plane block after mid-sternotomy incision for cardiac surgery.

Introduction: Most cardiac surgeries are performed through a median sternotomy, of which 49% of these patients experience severe pain at rest postoperatively and up to 78% on coughing and deep breathing. Regional thoracic wall blocks targeting thoracic nerve roots improve the analgesia quality and limit opioid use. Truncal blocks through the posterior approach can often be cumbersome in patients with multiple lines and catheters. Pecto-Intercostal Fascial Plane Block (PIFB) can be a convenient alternative for achieving comparable analgesia. Material and methods: The patients were randomly assigned to receive either an ultrasound-guided Pecto-Intercostal Fascial Plane Block (PIFB) or Erector Spinae Plane Block (ESPB). The outcomes measured and compared postoperative pain scores at rest and on deep breathing at 2, 6, 12, 24 h, total opioid (fentanyl) consumption in the postoperative period, time to rescue analgesia and total rescue analgesic doses required, between the two groups. Results: Data from 30 patients were analysed. Post-operative pain scores at rest and during deep breathing were found to be comparable in both groups. The total opioid consumed, time to rescue analgesia and total doses of rescue analgesia was not found to be statistically different in the two groups. Conclusions: PIFB was found to be comparable to ESPB in alleviating post-operative pain in patients who underwent cardiac surgeries through sternotomy. And it/PIFB can be a quicker alternative to posterior truncal blocks since it can be safely given in a supine position with an ultrasound.

Preintubation Machine-Delivered Pressure Support Ventilation With Positive End-Expiratory Pressure Versus Manual Bag-Mask Ventilation for Oxygenation in Overweight and Obese Patients: A Randomized, Pilot Study.

BACKGROUND: Noninvasive positive pressure ventilation (NIPPV) maintains mean airway pressures well, and its usability for preoxygenation is well described. Anesthesia machine-delivered NIPPV-based preoxygenation has recently been evaluated against the traditional manual bag-mask ventilation (BMV). The efficiency of such a technique over the traditional one is yet to be established well. The present study evaluated the feasibility of machine-delivered preoxygenation using pressure support ventilation (PSV) with positive end-expiratory pressure (PEEP) and compared the effectiveness with BMV. METHODS: Thirty overweight and obese adults belonging to the American Society of Anesthesiologist's physical status I-II were randomized to receive PSV+PEEP or BMV for preintubation preoxygenation targeted to a fraction of expired oxygen (FeO2) of 85% and 90% or for a maximum period of five minutes, whichever came first. Postintubation, the patient was observed for the time taken until 1% desaturation without ventilation. Arterial blood gases, respiratory variables, FeO2 achieved, and different times were collected and compared. RESULTS: The baseline characteristics and arterial blood gases were similar between the two groups. The PSV+PEEP group had consistent and favorable tidal volume and airway pressure delivery. The difference in time to reach a FeO2 of 85% between the two groups was not statistically different. Only two patients achieved a FeO2 of 90% in the PSV+PEEP group versus none in the BMV group. However, partial pressure of oxygen at 1% desaturation (217.42±109.47 versus 138.073±71.319 mmHg, p 0.0259) was higher in the PSV+PEEP group. Similarly, the time until 1% desaturation was significantly prolonged in the PSV+PEEP group (206.6±76.952 versus 140.466±54.245 seconds, p 0.0111). CONCLUSION: The present pilot study findings indicate that preintubation machine-delivered PSV+PEEP-based preoxygenation is feasible and might be more effective than traditional BMV in overweight and obese patients.

Incidence of postoperative pulmonary congestion as diagnosed by lung ultrasound in surgeries performed under general anaesthesia: A prospective, observational study.

Background and Aims: Administering liberal fluid raises concerns about pulmonary congestion postoperatively. Bedside ultrasonography is a valuable tool for the early detection of pulmonary congestion. In this study, we have used it to ascertain the impact of the duration of surgery and intraoperative fluid volume on the causation of pulmonary congestion. Our objective was to determine the incidence of pulmonary congestion as diagnosed by lung ultrasound in patients undergoing general anaesthesia with varied fluid administration. Methods: Seventy participants of American Society of Anesthesiologists physical status I and II, aged between 18 and 60 years, undergoing elective extrathoracic surgeries of over 3 h under general anaesthesia were included. Preoperative lung ultrasound was carried out in all patients, and a postoperative lung ultrasound was carried out at 1 h after extubation. The appearance of three or more "B"-lines was considered positive for lung congestion. Results: Significant differences (P < 0.001) were found in the duration of surgery and the appearance of B-lines in the postoperative period. Participants who developed B lines received, on average, 150% more fluid (1148.16 ± 291.79 ml) than those who did not (591.29 ± 398.42 ml) (P = 0.0240). Net fluid balance was also significantly different in patients who developed B lines (P = 0.0014). None of the patients developed symptoms of lung congestion postoperatively. Conclusion: Long duration of surgery under general anaesthesia (>3 h) with the administration of large volumes of intraoperative fluid and a large net fluid balance are associated with lung congestion as diagnosed by lung ultrasound.

Efficacy of flupirtine for postoperative pain: A systematic review and meta-analysis.

Background and Aims: Flupirtine has been used for various chronic pain conditions, but its utility in the perioperative period as an analgesic is still inconclusive. This systematic review and meta-analysis aimed to assess the efficacy of flupirtine for postoperative pain. Methods: PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) were explored for the randomised controlled trials (RCTs) which compared flupirtine with other analgesic/placebo for perioperative pain in adult patients undergoing surgery. The standardised mean difference (SMD) of pain scores, the need for rescue analgesia and all adverse effects were assessed. Heterogeneity was assessed using Cochrane's Q statistic test and I2 statistic. Cochrane Collaboration's tool was used to evaluate the risk of bias and the quality of the RCTs. Results: A total of 13 RCTs (including 1,014 patients) that evaluated the use of flupirtine for postoperative pain were included in the study. The pooled SMD of postoperative pain scores revealed that flupirtine and other analgesics were comparable at 0, 6, 12 and 24 hours (P > 0.05), while at 48 hours, flupirtine showed poor pain control (P = 0.04) as compared to other analgesics. There were no significant differences at other time points and on comparison of flupirtine with placebo. The side effect profile was comparable between flupirtine and other analgesics. Conclusion: The current evidence suggests that perioperative flupirtine was not superior to other most commonly used analgesics and placebo for the treatment of postoperative pain.

Effect of Postoperative Anesthesiologists' Single Visit on Patient Satisfaction: A Hospital-Based Non-Randomized Study.

Background Continuity of personal care by the anesthesiologist is crucial for patient satisfaction. Over and above the consultation and service in the preoperative area, intraoperative care, and post-anesthesia care unit, anesthesia services frequently incorporate a pre-anesthesia evaluation clinic and a preoperative visit in the inpatient ward for their services, which helps with rapport building. However, routine post-anesthesia visits in the inpatient ward by the anesthesiologist are infrequent, causing a break in the continuity of care. The effect of such a routine post-operative visit by anesthesiologists has been tested only rarely in the Indian population. The present study aimed to evaluate the impact of a single postoperative visit by the same anesthesiologist (continuity of care) on patient satisfaction and compare it with a postoperative visit by another anesthesiologist and no postoperative visit. Methods After institutional ethical committee approval, 276 American Society of Anesthesiologists physical status (ASA PS) I and II, consenting, elective surgical inpatients older than 16 years were enrolled in a tertiary care teaching hospital from January 2015- September 2016. Consecutive patients were allocated into three groups based on the postoperative visit (i.e., group A: by the same anesthesiologist; group B: another anesthesiologist; and group C: no visit). Data related to patients' satisfaction were collected in a pretested questionnaire. Chi-Square and Analysis of Variance (ANOVA) were applied to analyze the data and compare among the groups; a p < 0.05 was considered statistically significant.  Results The mean age of the entire cohort was 38.1 years, comprising 39.9% men. Demographic, socioeconomic, and educational statuses were similar in all groups (p >0.05). The percentages of patient satisfaction were 61.47%, 51.52%, and 38.5% in groups A, B, and C, respectively (p=0.0001). Satisfaction with the fulfillment of "continuity of personal care" was the highest for group A (69.35%), which was significantly higher than group B (43.69%) and group C (35.65%). Group C had the lowest fulfillment of patient expectations and was significantly less satisfied than even group B (p=0.02). Conclusion Continuity of anesthesia care with the addition of routine postoperative visits had the highest positive impact on patient satisfaction. Even a single postoperative visit by the anesthesiologist significantly increased the patients' satisfaction.

Recent trends in chronic pain medicine.

Chronic pain presents as an unequalled challenge for physicians, owing to the complexity of biochemical and biological pathways involved in pain transmission and high variability of pain perception among individuals. Often, there is an inadequate response to conservative treatment, and opioid treatment has its own drawbacks, such as side effects and opioid dependence. Hence, novel strategies have evolved for the effective and safe management of chronic pain. Radiofrequency technique, regenerative biomaterial, platelet-rich plasma, mesenchymal stem cells, reactive oxygen species scavenger nanomaterial, ultrasound-guided interventional pain management procedures, endoscopic spinal procedures, vertebral augmentation therapy, and neuromodulation are some of the promising and upcoming modalities in the armamentarium of pain physicians.

Ultrasound-Guided Right Internal Jugular Vein Cannulation by Operators of Different Experience: A Randomized, Pilot Study.

BACKGROUND AND AIM: Currently, ultrasound-guided (US-guided) internal jugular vein (IJV) cannulation is the recommended technique. However, it has a learning curve and might be unsafe in inexperienced hands. The present study aimed to compare the performance and complications with two levels of experience in performing US-guided right IJV cannulation. METHODS: With informed consent, 108 procedures were performed after random allocation into two groups based on operator experience. An operator with experience in performing 30 or more ultrasound-guided IJV cannulation was considered an expert. The rate of successful cannulation, the time needed, number of attempts, and complication rate were measured. Quantitative continuous variables were compared using the unpaired student's t-test, and the chi-square test or Fisher's-exact test was used for the comparison of qualitative variables; P-value < 0.05 was considered significant. RESULTS: The successful cannulation rates were 100% versus 94.44% in the expert and non-expert groups, respectively; (P=0.0803). The mean time for successful cannulation and the percentage of patients who required ≥ two attempts were significantly lower in the expert group (33.28 seconds and 12.96% versus 95.42 seconds and 61.12%). Although the incidence of carotid artery puncture and hematoma (7.4% and 5.56%) was higher in the non-expert group, it was not statistically different; (P=1.00). CONCLUSION: US-guided right IJV cannulation has a learning curve, and procedures as many as 30 US-guided IJV cannulation need to be observed and performed under the guidance to achieve it.

Posterior Reversible Encephalopathy Syndrome: Nitroglycerine a Friend or a Foe?

Posterior reversible encephalopathy syndrome (PRES) refers to a clinico-radiological entity with characteristic features on neuroimaging and rapid onset of nonspecific symptoms including headache, seizure, altered consciousness and visual disturbance. It is a neurotoxic state in response to the acute changes in blood pressure leading to vasogenic oedema. It is often but not always associated with hypertension. However, control blood pressure is one of the mainstays of management in such cases. Nitroglycerine (NTG) is a potent vasodilator and is one of the drugs for treatment of hypertensive emergencies. It is found to worsen the cerebral oedema in PRES which is considered due to failure of cerebral blood pressure autoregulation. Here, we report two such cases where patients with PRES deteriorated with NTG infusion. However, the neurological condition of the patients improved drastically the next day. NTG could have further enhanced vasodilation, thus aggravating developing PRES, after autoregulation was lost because of high blood pressure.

How Robust are the Evidences that Formulate Surviving Sepsis Guidelines? An Analysis of Fragility and Reverse Fragility of Randomized Controlled Trials that were Referred in these Guidelines.

OBJECTIVES: "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016" provides guidelines in regard to prompt management and resuscitation of sepsis or septic shock. The study is aimed to assess the robustness of randomized controlled trials (RCTs) that formulate these guidelines in terms of fragility index and reverse fragility index. METHOD: RCTs that contributed to these guidelines having parallel two-group design, 1:1 allocation ratio, and at least one dichotomous outcome were included in the study. The median fragility index was calculated for RCTs with significant statistical outcomes, whereas the median reverse fragility index was calculated for RCTs with nonsignificant statistical results. RESULTS: Hundred RCTs that met the inclusion criteria were analyzed. The median fragility index was 5.5 [95% confidence interval (CI) 1-30] and median reverse fragility index was 13 (95% CI 12.07-16.8) at a p value of 0.05. The median reverse fragility index was 16 (95% CI 10-26) at a p value of 0.01. Most of the RCTs included in this analysis were of good quality, having a median Jadad score of 6. CONCLUSION: This analysis found that the surviving sepsis guidelines were based on highly robust RCTs with statistically insignificant results and on some moderately robust RCTs with statistically significant results. RCTs with statistically insignificant results were more robust than RCTs with statistically significant results in regard to these guidelines. HIGHLIGHTS: The study assessed the robustness of randomized controlled trials (RCTs) that were used to formulate surviving sepsis guidelines. Most RCTs showed statistically nonsignificant results. RCTs with statistically significant results were moderately fragile whereas RCTs with nonsignificant results were more robust. HOW TO CITE THIS ARTICLE: Choupoo NS, Das SK, Saikia P, Dey S, Ray S. How Robust are the Evidences that Formulate Surviving Sepsis Guidelines? An Analysis of Fragility and Reverse Fragility of Randomized Controlled Trials that were Referred in these Guidelines. Indian J Crit Care Med 2021;25(7):773-779.

Re: evaluation of the efficacy of erector spinae plane block and intercostal nerve block in the postherpetic neuralgia.

Not applicable.

Effect of Two Different Tranexamic Acid Doses on Blood Loss in Head and Neck Cancer Surgery: A Randomized, Double-Blind, Controlled Study.

Background and aim Head and neck cancer is frequent, and surgeries pose more significant morbidity and mortality due to multitudinal causes; heavy blood loss and transfusion are among them. Tranexamic acid (TXA) is known to stabilize the micro clots hence controlling excessive blood loss. The present study aimed to compare perioperative blood loss with two different doses of TXA and placebo to find the effectiveness and optimal dose. Methods With ethical approvals and informed consent, the present prospective, randomized, double-blind, controlled study was conducted in a teaching institute from May 31, 2018, to Dec 28, 2019. Patients undergoing elective head and neck cancer (HNC) surgeries were included. Preoperative Hb < 7 gm% or > 16 gm%, known coagulopathy, anticoagulant therapy, contraindications to TXA, intraoperative torrential or blood loss due to arterial injury were excluded. Group T-1 received TXA 10mg/kg, T-II received 15 mg/kg, while the control group (Gr-C) received equal volume normal saline. Data about demography, surgical time, intraoperative and postoperative blood loss, and transfusion were collected and compared. SPSS software was used for analysis; p-value <0.05 was considered significant. Results Ninety patients were screened, 84 completed the study. All three groups were similar in demographics. The median blood loss with 25th -75th percentile in group C, T-I, and T-II groups were 762.5 (513.5-1193), 541.5 (296.5-787), and 536.0 (180.5 - 879) mL, respectively; p: 0.025. There was a significant difference between the control group and T-I (p-value: 0.0153), and control and T-II (p-value: 0.0248), but an insignificant difference between T-I and T-II (p-value: 0.706). 5 (17.85%) in each of T-I and T-II required transfusion, whereas 14 (50%) in the control group required it; p < 0.011). No major clinically significant related to study drugs were noted. Conclusion Compared to placebo (normal saline), preoperative administration of TXA in bolus significantly reduced perioperative blood losses and transfusion requirement in patients undergoing HNC surgery as estimated using the Hb-based method. A bolus dose of doses of 10mg/kg and 15 mg/kg is equally effective.

Antiemetic Efficacy of Palonosetron Compared with the Combination of Ondansetron and Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Gynaecological Surgery.

Background and aims: For the prevention of PONV, we evaluated the efficacy of palonosetron compared with ondansetron along with dexamethasone in patients undergoing laparoscopic gynaecological surgery. Methods: A total of 84 adults, posted for elective laparoscopic surgeries under general anaesthesia were included in the study. The patients were randomly allocated to two groups (n = 42 each). Immediately after induction, patients in the first group (group I) received 4 mg ondansetron with 8 mg dexamethasone, and patients in the second group (group II) received 0.075 mg palonosetron. Any incidences of nausea and/or vomiting, the requirement of rescue antiemetic, and side effects were recorded. Results: In group I, 66.67% of the patients had an Apfel score of 2, and 33.33% of the patients had a score of 3. In group II, 85.71% of patients had an Apfel score of 2, and 14.29% of the patients had a score of 3. At 1, 4, and 8 hours, the incidence of PONV was comparable in both groups. At 24 hours there was a significant difference in the incidence of PONV in the group treated with ondansetron with dexamethasone combination (4/42) when compared to the palonosetron group (0/42). The overall incidence of PONV was significantly higher in group I (23.81%: ondansetron and dexamethasone combination) than in group II (7.14%: palonosetron). The need for rescue medication in group I was significantly high. Conclusion: Palonosetron was more efficacious compared to the combination of ondansetron and dexamethasone for preventing PONV for laparoscopic gynaecological surgery.

A retrospective comparison of preoperative estimated glomerular filtration rate as a predictor of postoperative cardiac surgery associated acute kidney injury.

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) remains common with distressingly high mortality. Over time, risk scorings systems have been developed to predict it and preoperative low estimated glomerular filtration rate (eGFR) has been regarded as one of the predicting risk factors. Objectives: The present study is aimed at assessing the relation of different ranges of preoperative eGFR with an incidence of CSA-AKI defined by the AKI network (AKIN) criteria. Materials and Methods: Files of 134 patients with eGFR of >40 cc/min/1.73 m2 body surface area (BSA) who underwent cardiac surgeries on cardiopulmonary bypass were screened for data collection. Occurrences of CSA-AKI were evaluated as per the AKIN criteria over the course of 3 postoperative days. The relationships of different ranges of preoperative eGFR with CSA-AKI were analyzed by appropriate statistical tests using Instat software and P < 0.05 was considered statistically significant. Results: A total of 60 males and 74 females with a mean + standard deviation (SD) age of 37.98 ± 12.50 years and mean + SD preoperative eGFR of 70.20 ± 20.89 cc/min/1.73 m2 were analyzed in this study. About 49.25% of patients suffered from CSA-AKI by the 3rd postoperative day. The crude risk of CSA-AKI in patients with eGFR 40-60 cc/min/1.73 m2 was not higher (odds ratio 0.29) as compared to patients in patients with eGFR >100 cc/min/1.73 m2. The CSA-AKI trend with different eGFR was also statistically insignificant (P > 0.05). Conclusion: In patients with preoperative eGFR >40 cc/min/1.73 m2 BSA, a lower preoperative eGFR (40-60 cc/min/1.73 m2) does not predict higher incidence of CSA-AKI as defined by AKIN criteria as compared to higher preoperative eGFR (>100 cc/min/1.73 m2). Lower height is independently associated with higher incidence of CSA-AKI in such patients.

Effect of different doses of intrathecal nalbuphine as adjuvant to ropivacaine in elective lower limb surgeries: A dose finding study.

BACKGROUND AND AIM: Nalbuphine as an adjuvant intrathecally can produce significant analgesia with minimal side effects. However, no research has been done with isobaric ropivacaine. We, therefore, in this prospective, randomised double-blind study tried to find the optimal dose of intrathecal nalbuphine with isobaric 0.75% ropivacaine for elective lower limb surgeries. MATERIALS AND METHODS: One hundred American Society of Anaesthesiologists I and II patients undergoing elective lower limb surgery were divided into four groups randomly: groups A, B, C and D, who received 0.5 mL normal saline or 0.4, 0.8 and 1.6 mg nalbuphine made up to 0.5 mL normal saline added to 22.5 mg (total volume 3.5 mL) isobaric 0.75% ropivacaine, respectively. The onset of sensory and motor block, two-segment regression time, duration of sensory and motor block, Visual Analogue Scale (VAS) and the incidence of adverse effects were compared between the groups. RESULTS: The onset of both sensory and motor blockade was faster with addition of 0.4, 0.8 and 1.6 mg of nalbuphine when compared with ropivacaine alone; however, it was not statistically significant (P > 0.05). Two-segment regression time and duration of analgesia and motor blockade were highest with 1.6 mg of nalbuphine followed by 0.8, 0.4 and plain 0.75% ropivacaine (P < 0.05). The duration of sensory blockade in all four groups was slightly more than the duration of motor blockade. VAS readings were comparable in all nalbuphine groups when compared with ropivacaine group. Haemodynamic variability among the four groups was comparable. Incidence of adverse effects was highest in the 1.6-mg group when compared with others, although it was statistically insignificant (P > 0.05). CONCLUSION: Nalbuphine can be a good alternative to other opioids as an adjuvant intrathecally to prolong postoperative analgesia with a minimal side effect profile. Addition of nalbuphine to isobaric 0.75% ropivacaine gives the added advantage of significant analgesia with early motor recovery. We infer from our study that when compared with 1.6 mg of nalbuphine, both 0.4 and 0.8 mg nalbuphine are equally good as adjuvants to isobaric 0.75% ropivacaine in elective lower limb surgeries with prolonged analgesia, a reliable block with equal efficacy but with lesser side effects.