Intermittent Transcutaneous Electrical Nerve Stimulation versus Transversus Abdominis Plane Block for Postoperative Analgesia after Infraumbilical Surgeries.

BACKGROUND: Multimodal analgesia is currently recommended for effective postoperative analgesia. AIM: The aim of this study is to compare the efficacy of transversus abdominis plane (TAP) block with intermittent transcutaneous electrical nerve stimulation (TENS) in postoperative patients after infraumbilical surgeries under spinal anesthesia with respect to postoperative analgesia, rescue analgesia, hemodynamic changes, block characteristics, nausea/vomiting score, sedation score, adverse effects, and patient satisfaction. SETTINGS AND DESIGN: This was a prospective, observational study randomized controlled trial. METHODS: A total of 60 American Society of Anesthesiologists physical status Classes I and II patients of 20-60 years scheduled for infraumbilical surgeries were randomized by a computer-generated list into two groups of 30 each, to receive either TAP Block (Group TAP: 15 ml of 0.25% levobupivacaine on each side of abdomen) or TENS (Group TENS: TENS with frequency of 50 Hz and intensity of electrical stimulation 9-12 mA, continued for 30 min every 2 h till 24 h). The primary outcome was to compare the postoperative analgesia as assessed using visual analog scale score. Secondary objectives were to compare rescue analgesia, nausea/vomiting score, sedation score, the block characteristics, adverse effects, hemodynamic changes, and patient satisfaction. STATISTICAL ANALYSIS USED: Student's t-test, Chi-square test as applicable and Statistical Package for Social Sciences (version 23.0, 2017, SPSS Inc., Chicago, IL, USA) were used. RESULTS: Time to the first analgesic requirement was 12.87 ± 4.72 h in Group TAP and 9.93 ± 3.63 h in Group TENS (P < 0.008), the difference between two groups was significant. CONCLUSION: TAP block is better modality due to ease of application and prolonged analgesia.

Advantages of 1-1-12 Wash in Scheme during Induction with Low Flow Anesthesia with and without Nitrous Oxide.

INTRODUCTION: In the past, many wash-in schemes have been used with initially high fresh gas flow (FGF) to achieve the necessary alveolar concentration of inhalational agent in 10-15 min. This study was designed to show whether 1-1-12 wash-in scheme proposes an earlier achievement of induction or is there any requirement of high FGF phase to know the time taken for induction with and without nitrous oxide (N2O). AIMS: The aim of the study was to find out the time required for the alveolar concentration of desflurane to be from 1% to 6% with and without N2O. DESIGN: It was a potential randomized study which was conducted on sixty patients admitted for elective surgery. MATERIALS AND METHODS: Two groups of thirty patients each were made and randomly assigned. Group N received desflurane with N2O plus oxygen and Group A received desflurane with air plus oxygen. STATISTICAL ANALYSIS: The observations were noted and evaluated accordingly. Analysis was done using unpaired t-test. RESULTS: Hemodynamic parameters were almost similar in both the groups. In Group N, gradual FAD (Alveolar Desflurane concentration, i.e., end-tidal desflurane) from 1% to 6% was achieved at 0.5, 1, 1.5, 2, 3, and 4 min. In Group A, the same was achieved at 0.6, 1, 1.5, 2, 3, and 4 min (P > 0.05). No significant difference was found between the recuperation time and score in both the groups. Rather complications were more in Group N and statistically significant for nausea and vomiting. CONCLUSION: Time taken to attain FAD from 1% to 6% was 4 min in both the groups. It is concluded that the recitation of 1-1-12 wash-in scheme is autonomous on the use of N2O and high FGF phase.

Comparison of Spinal Anesthesia and Paravertebral Block in Inguinal Hernia Repair.

CONTEXT: Inguinal hernia repair (IHR) is a common surgical procedure which can be performed under general, regional, or peripheral nerve block anesthesia. AIM: The aim of our study was to compare the efficacy of paravertebral block (PVB) with spinal anesthesia (SA) for IHR with respect to postoperative analgesia, ambulation, and adverse effects. SETTINGS AND DESIGN: This was a prospective, single-blind randomized controlled trial. MATERIALS AND METHODS: Sixty American Society of Anesthesiologists Class I-II patients of 20-60 years scheduled for IHR were randomized by a computer-generated list into two groups of thirty each, to receive either PVB (Group PVB: at T12-L2 levels, 10 ml of 0.5% levobupivacaine at each level) or SA (Group SA: at L3-L4/L2-L3 level, 2.5 ml of 0.5% levobupivacaine). Primary outcome was duration of postoperative analgesia and time to reach discharge criteria. Secondary outcome was time to ambulation, time to perform the block, time to surgical anesthesia, total rescue analgesic consumption, adverse effects, hemodynamic changes, patient, and surgeon satisfaction. STATISTICAL ANALYSIS USED: Student's t-test, Chi-square test as applicable, and Statistical Package for Social Sciences (version 14.0, SPSS Inc., Chicago, IL, USA) were used. RESULTS: Time to the first analgesic requirement was 15.17 ± 3.35 h in Group PVB and 4.67 ± 1.03 h in Group SA (P < 0.001). Time to reach the discharge criteria was significantly shorter in Group PVB than Group SA (P < 0.001). CONCLUSION: PVB is advantageous in terms of prolonged postoperative analgesia and encourages early ambulation compared to SA.

Conscious Sedation: Emerging Trends in Pediatric Dentistry.

Dental fear and anxiety is a common problem in pediatric patients. There is considerable variation in techniques used to manage them. Various sedation techniques using many different anesthetic agents have gained considerable popularity over the past few years. Children are not little adults; they differ physically, psychologically, and emotionally. The purpose of this review is to survey recent trends and concerning issues in the rapidly changing field of pediatric sedation. We will study the topic from the perspective of an anesthesiologist. It will also provide information to practitioners on the practice of conscious sedation in dentistry and will also outline the route of administration, pharmacokinetics, and pharmacodynamics of various drugs used.

Impact of different intravenous fluids on blood glucose levels in nondiabetic patients undergoing elective major noncardiac surgeries.

BACKGROUND: Intravenous (IV) fluids are an integral part of perioperative management. Intraoperative hyperglycemia is associated with poor clinical outcomes in patients undergoing major surgeries even in nondiabetics. AIM: This study was conducted to observe the effect of different maintenance fluid regimens on intraoperative blood glucose levels in nondiabetic patients undergoing major surgeries under general anesthesia. SETTINGS AND DESIGN: Randomized double-blind study. MATERIALS AND METHODS: One hundred nondiabetic patients of either sex were divided randomly into two Groups I and II of 50 each undergoing elective major surgeries of more than 90 min duration under general anesthesia. Both groups were given calculated dosage of IV fluids accordingly 4-2-1 formula while Group I was given Ringer lactate (RL) and Group II was given 0.45% dextrose normal saline and potassium chloride 20 mmol/L. Changes in vital parameters, % oxygen saturation, and urine output were monitored at regular intervals. Capillary blood glucose (CBG) was measured half-hourly until end of surgery. If CBG level was more than 150 mg%, then calculated dose of human insulin (CBG/100) was given as IV bolus dose. STATISTICAL ANALYSIS: Statistical analysis was done using SPSS 22.0 software (IBM Corporation, Armonk, New York, USA), paired t-test and Chi-square test. RESULTS: A significant increase of CBG level and was observed during intraoperative and immediate postoperative period (P < 0.001) in Group II. CONCLUSION: RL solution is probably the alternative choice of IV fluid for perioperative maintenance and can be used as replacement fluid in nondiabetic patients undergoing major surgeries.

Regional anesthesia in difficult airway: The quest for a solution continues.

Difficult airway, a scenario with potentially life threatening outcome, is routinely encountered by an anesthesiologist leaving him with the dilemma of whether to use regional anesthesia (RA) or general anesthesia. Our study aims to look into this problem. The literature search was performed in the Google, PubMed, and Medscape using key words "regional anesthesia, difficult airway, pregnancy, ventilation, intubation, epidural anesthesia, nerve blocks." More than 38 free full articles and books published from the year 1987 to 2014 were retrieved and studied. At first sight, RA may appear to offer an ideal solution as it helps to avoid the problem of difficult airway. However, the possibility of a total spinal block, failed or incomplete RA, local anesthetic toxicity or unforeseen surgical complication may make it imperative that the airway is secured. The correct decision can only be made by the anesthetist when all the relevant clinical information is taken into account. It is also important to ensure that before considering RA in a patient of difficult airway, an anesthesiologist must have a preformulated strategy for intubation.

Gabapentin vs pregabalin as a premedication in lower limb orthopaedics surgery under combined spinal epidural technique.

BACKGROUND: Pregabalin and gabapentin are the gamma-aminobutyric acid analogs used as a part of multimodal analgesic regimen. AIM: To compare the postoperative analgesic benefits of gabapentin or pregabalin as a premedication for lower limb orthopedic surgery under combined spinal-epidural techniques. SETTINGS AND DESIGN: Randomized double-blind study. MATERIALS AND METHODS: A total of 90 patients were divided into three groups: G, P, C who received gabapentin 1200 mg, pregabalin 300 mg, and placebo, respectively 1.5 h before surgery. All patients received combined spinal-epidural block with 3 ml of 0.5% intrathecal bupivacaine. Assessment of pain was made with visual analog scale (VAS). Postoperative analgesia was provided with epidural top-ups with 2.5 ml of 0.5% bupivacaine and fentanyl 25 µg when VAS >3. Rescue analgesia in the form of injection diclofenac (75 mg) intramuscularly was given if VAS >3 even after epidural top-up. A total number of epidural top-ups, rescue analgesia, pain-free interval postspinal anesthesia, and sedation score were noted. STATISTICAL ANALYSIS: This was done using SPSS version 17. Mean and standard deviation were calculated using Chi-square test and analysis of variance. RESULTS: The total postoperative analgesic time was 7.23 h in Group G, 14.80 h in Group P, and 4.17 h in Group C. A total number of epidural top-ups were 2.43 in Group G, 0.77 in Group P, and 4.43 in Group C. CONCLUSION: Pregabalin 300 mg and gabapentin 1200 mg significantly reduce the need of postoperative rescue analgesia, epidural top-ups, and increase the duration of postspinal anesthesia without altering hemodynamics with sedation as a major side effect.

Sevoflurane in low-flow anesthesia using "equilibration point".

CONTEXT: While giving low-flow anesthesia, it is a routine practice to give fixed duration of initial high-flow. This study was conducted to show the use of equilibration point as changeover point from initial high-flow to low-flow. AIMS: It was to compare the use of equilibration point, hemodynamics, end-tidal agent concentration, recovery time, and recovery score between isoflurane and sevoflurane. SETTINGS AND DESIGN: It was a prospective randomized study conducted on 100 patients who were admitted for elective surgery expected to be < 2 h duration. MATERIALS AND METHODS: Patients were randomly assigned to one of the two groups of 50 each. Group I received isoflurane and Group S sevoflurane as an inhalational agent. STATISTICAL ANALYSIS: The observations obtained in both the groups were recorded and compared. Analysis was done using unpaired t-test and Chi-square test. RESULTS: Hemodynamic parameters were comparable in both the groups. The mean equilibration times obtained for sevoflurane and isoflurane were 8.22 ± 1.060 min and 17.24 ± 10.2 min, respectively. The drift in end-tidal agent concentration over time was less in sevoflurane group. Mean recovery time was 7.92 ± 1.56 min in the sevoflurane group and 12.89 ± 3.45 min in the isoflurane group (P = 0.001). There was no significant difference between intraoperative and postoperative complications. CONCLUSION: Use of equilibration time of the volatile anesthetic agent as a changeover point, from high-flow to low-flow, can help us to use circle system with low-flow anesthesia in a more efficient way, especially with newer anesthetics such as sevoflurane.

Anesthetic considerations in the patients of chronic obstructive pulmonary disease undergoing laparoscopic surgeries.

The aim of this study was to review the various anesthetic options which can be considered for laparoscopic surgeries in the patients with the chronic obstructive pulmonary disease. The literature search was performed in the Google, PubMed, and Medscape using key words "analgesia, anesthesia, general, laparoscopy, lung diseases, obstructive." More than thirty-five free full articles and books published from the year 1994 to 2014 were retrieved and studied. Retrospective data observed from various studies and case reports showed regional anesthesia (RA) to be valid and safer option in the patients who are not good candidates of general anesthesia like patients having obstructive pulmonary diseases. It showed better postoperative patient outcome with respect to safety, efficacy, postoperative pulmonary complications, and analgesia. So depending upon disease severity RA in various forms such as spinal anesthesia, paravertebral block, continuous epidural anesthesia, combined spinal epidural anesthesia (CSEA), and CSEA with bi-level positive airway pressure should be considered.

Epidural nalbuphine for postoperative analgesia in orthopedic surgery.

BACKGROUND: The challenging task of postoperative pain relief comes within the realm of the anesthesiologist. Combined spinal epidural (CSE) anesthesia can be used as the sole technique for carrying out surgical procedures and managing postoperative pain using various drug regimes. Epidural administration of opioids in combination with local anesthetic agents in low dose offers new dimensions in the management of postoperative pain. AIMS: Comparative evaluation of bupivacaine hydrochloride with nalbuphine versus bupivacaine with tramadol for postoperative analgesia in lower limb orthopedic surgeries under CSE anesthesia to know the quality of analgesia, incidence of side effects, surgical outcome and level of patient satisfaction. SETTINGS AND DESIGN: A prospective, randomized and double-blind study was conducted involving 80 patients of American Society of Anesthesiologists physical status I and II coming for elective lower limb orthopedic surgeries carried under spinal anesthesia. MATERIALS AND METHODS: Anesthesia was given with 0.5% of 2.5 ml bupivacaine intrathecally in both the groups. Epidurally 0.25% bupivacaine along with 10 mg nalbuphine (group A) or tramadol 100 mg (group B) diluted to 2 ml to make a total volume of 10 ml was administered at sensory regression to T10. STATISTICAL ANALYSIS: The data were collected, compiled and statistically analyzed with the help of MS Excel, EPI Info 6 and SPSS to draw the relative conclusions. RESULTS AND CONCLUSIONS: The mean duration of analgesia in group A was 380 ± 11.49 min and in group B was 380 ± 9.8 min. The mean sedation score was found to be more in group B than group A. The mean patient satisfaction score in group A was 4.40 ± 0.871 and in group B was 3.90 ± 1.150 which was found to be statistically significant (P < 0.05). We concluded that the addition of nalbuphine with bupivacaine was effective for postoperative analgesia in terms of quality of analgesia and patient satisfaction score as compared to tramadol.

Intrathecal dextmedetomidine to reduce shoulder tip pain in laparoscopic cholecystectomies under spinal anesthesia.

BACKGROUND: General anesthesia as a technique for laparoscopic cholecystectomies has disadvantage in terms of the stress response, lack of postoperative analgesia and emesis. Regional anesthesia offers advantages over general anesthesia in terms of cost, postoperative analgesia, intact respiratory control mechanism and early ambulation. Shoulder tip pain remains the main concerns that can be alleviated by adding various adjuvants to local anesthetics. AIMS AND OBJECTIVES: To study the effect of adding intrathecal dexmedetomidine to bupivacaine to decrease shoulder tip pain, onset and duration of sensory and motor block, hemodynamic changes and side effects if any. MATERIALS AND METHODS: Totally, 60 patients were divided into two groups of 30 each. Group A received 3 ml of bupivacaine heavy and group B received 5 µg of dexmedetomidine along with 3 ml of bupivacaine diluted to total volume of 3.5 ml in each group. STATISTICAL ANALYSIS: It was done using Chi-square and Student's t-test. RESULTS AND CONCLUSIONS: Intrathecal dexmedetomidine provides stable hemodynamics, excellent sedation and analgesia and abolishes shoulder tip pain.

Fluid management in patients with trauma: Restrictive versus liberal approach.

Trauma is a leading cause of death worldwide, and almost 30% of trauma deaths are due to blood loss. A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. Some recent studies have shown that early volume restoration in certain types of trauma before definite hemostasis may result in accelerated blood loss, hypothermia, and dilutional coagulopathy. This review discusses the advances and changes in protocols in fluid resuscitation and blood transfusion for treatment of traumatic hemorrhage shock. The concept of low volume fluid resuscitation also known as permissive hypotension avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that although lower than normal, is adequate for short periods. Permissive hypotension is part of the damage control resuscitation strategy, which targets the conditions that exacerbate hemorrhage. The elements of this strategy are permissive hypotension, minimization of crystalloid resuscitation, control of hypothermia, prevention of acidosis, and early use of blood products to minimize coagulopathy.

Fentanyl versus tramadol with levobupivacaine for combined spinal-epidural analgesia in labor.

BACKGROUND: Neuraxial labor analgesia using new local anesthetics such as levobupivacaine has become very popular by virtue of the safety and lesser motor blockade caused by these agents. Combined spinal-epidural analgesia (CSEA) has become the preferred method for labor analgesia as it combines benefits of both spinal analgesia and flexibility of the epidural catheter. Adding opioids to local anesthetic drugs provide rapid onset and prolonged analgesia but may be associated with several maternal and fetal adverse effects. The purpose of this study is to compare fentanyl and tramadol used in CSEA in terms of duration of analgesia and frequency of the adverse fetomaternal outcome. MATERIALS AND METHODS: A total of 60 primiparas with a singleton pregnancy in active labor were given CSEA after randomly allocating them in two groups of 30 each. Group I received intrathecal 2.5 mg levobupivacaine + 25 µg fentanyl followed by epidural top ups of 20 ml 0.125% solution of the same combination. Group II received 25 mg tramadol instead of fentanyl. Epidural top ups were given when parturient complained of two painful contractions (visual analogue scale ≥ 4). Data collected were demographic profile of the patients, analgesic qualities, side- effects and the fetomaternal outcome. RESULTS: Patients in Group II had significantly prolonged analgesia (145 ± 9 minutes) than in Group I (95 ± 7 minutes). Patients receiving fentanyl showed rapid onset of analgesia, but there were more incidence of side-effects like shivering, pruritus, transient fetal bradycardia, hypotension, nausea and vomiting. Only side-effect in the tramadol group was nausea and vomiting. During labor, maternal satisfaction was excellent. CONCLUSIONS: Adding tramadol to local anesthetic provides prolonged analgesia with minimal side effects. Fentanyl, when used as adjuvant to local anesthetic, has a rapid onset of analgesia but has certain fetomaternal side-effects.

Dilated cardiomyopathy: an anaesthetic challenge.

Idiopathic dilated cardiomyopathy is a primary myocardial disease of unknown etiology characterized by left ventricular or biventricular dilation and impaired contractility. Depending upon diagnostic criteria used, the reported annual incidence varies between 5 and 8 cases per 100,000 populations. Dilated cardiomyopathy is defined by presence of: a) fractional myocardial shortening less than 25% (>2SD) and/or ejection fraction less than 45% (>2SD) and b) Left Ventricular End Diastolic Diameter (LVEDD) greater than 117% excluding any known cause of myocardial disease. Such cases are always a challenge to the anesthesiologist as they are most commonly complicated by progressive cardiac failure. We report the anesthetic management of a patient with dilated cardiomyopathy undergoing surgery for carcinoma breast.

Evaluation of spinal and epidural anaesthesia for day care surgery in lower limb and inguinoscrotal region.

BACKGROUND: Day care surgery is still in its infancy in India. Both regional and general anaesthesia can be used for this. Central neuraxial blocks are simple cheap and easy to perform. This study was done to evaluate usefulness of spinal and epidural anaesthesia for day care surgery. PATIENTS #ENTITYSTARTX00026; METHOD: 100 patients were randomized to either spinal (n=50) or epidural (n=50) group anaesthetized with either 0.5% hyperbaric 2ml bupivacaine or 0.5% 20ml bupivacaine respectively. In spinal group 27 gauze quincke needle and in epidural group 18 gazue tuohy needle was used. Both the groups were compared for haemodynamic stability, side effects, complications, postanaesthesia discharge score (PADS), time taken to micturate, total duration of stay in hospital and patient satisfaction score for technique. RESULTS: We observed that spinal anaesthesia had significantly early onset of anaesthesia and better muscle relaxation (p<0.05) as compared to epidural block otherwise both groups were comparable for haemodynamic stability, side effects or complications. Although more patients in spinal group (64% vs 48%) achieved PADS earlier (in 4-8 hours) but statistically it was insignificant. Time to micturition (6.02 0.55 v/s 6.03 0.47 hours) and total duration of stay (7.49 1.36 v/s 8.03 1.33 hours) were comparable in both the groups. CONCLUSION: Both spinal and epidural anaesthesia can be used for day care surgery. Spinal anaesthesia with 27 gauze quincke needle and 2ml 0.5% hyperbaric bupivacaine provides added advantage of early onset and complete relaxation.