Intraperitoneal nebulization of ropivacaine for control of pain after laparoscopic cholecystectomy -A randomized control trial.

BACKGROUND AND AIMS: Use of high dose opioids following laparoscopic surgery delays discharge from the hospital. Unlike intraperitoneal instillation, nebulization has been reported to provide a homogeneous spread of local anesthetics and provide better analgesia. In our study, we aimed to assess the efficacy of intraperitoneal nebulization of local anesthetic in alleviating postoperative pain in patients undergoing laparoscopic cholecystectomy. MATERIAL AND METHODS: This randomized control double-blinded study was conducted after obtaining approval from the hospital ethics committee and informed consent from patients undergoing laparoscopic cholecystectomy under general anesthesia. Patients recruited were divided into two equal groups of 20 each. Group B received intraperitoneal nebulization with 4 ml of 0.75% ropivacaine and Group C received intraperitoneal nebulization with 4ml of saline before surgical dissection. Postoperative pain score using a numeric rating scale was monitored until 24 h, the need for rescue analgesics and associated complications were noted. Chi-square test, Student's test, and Mann-Whitney U test were used for statistical analysis. RESULTS: The pain score was significantly less in Group B during rest and deep breathing up to 24 h with a P value <0.05. The pain score on movement was also less in Group B and this difference was statistically significant at 6 and 24 h (P = 0.004 and 0.005, respectively). Tramadol consumption was less in Group B and was statistically significant at 24 h with P value of 0.044. No adverse events were noted. CONCLUSION: Intraperitoneal nebulization of ropivacaine is effective and safe in providing postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

Effectiveness and Safety of Extubation before Reversal of Neuromuscular Blockade versus Traditional Technique in Providing Smooth Extubation.

BACKGROUND: Traditional extubation often leads to bucking, coughing, and undesirable hemodynamic changes. Extubation just before administering reversal could reduce force of coughing, bucking and may provide better extubation conditions. AIM OF STUDY: The aim of the study was to assess the incidence of bucking with extubation just before administering reversal of neuromuscular blockade compared to traditional technique of awake extubation. Incidence of coughing during extubation, vomiting/regurgitation, aspiration, hemodynamic changes, postoperative bleeding, and extubation conditions were also assessed. SETTINGS AND DESIGN: This was a prospective randomized study conducted in a tertiary care institute. SUBJECTS AND METHODS: Forty patients were allocated into two equal groups. In Group E, at the end of surgery, extubation was performed and reversal was administered after extubation. In Group L, reversal was given and patients were extubated in the traditional way. Quality of extubation was assessed using extubation quality score. STATISTICAL TESTS USED: Pearson Chi-square test, Fisher's exact test, and independent sample t-test. RESULTS: Group E showed significantly lower incidence of bucking (15% vs. 65%) and coughing (10% vs. 45%). Incidences of desaturation and regurgitation/aspiration were comparable. In Group E, 85% of patients did not cough during extubation compared to 50% in Group L. Extubation quality was significantly better in Group E. Although extubation time was significantly shorter in Group E, recovery time was comparable in both groups. CONCLUSION: Extubation just before reversal of neuromuscular blockade resulted in lesser incidence of bucking and coughing during extubation with lesser postoperative bleeding compared to traditional technique of awake extubation without added risks of regurgitation, aspiration, or delayed recovery.

Effect of liberal versus restrictive fluid therapy on intraoperative lactate levels in robot- assisted colorectal surgery.

BACKGROUND AND AIMS: Minimally invasive and robotic surgeries need lesser fluid replacement but the role of restricted fluids in robotic surgeries other than prostatic surgeries has not been clearly defined. Our primary aim was to evaluate the effects of a restrictive fluid regimen versus a liberal policy on intra-operative lactate in robotic colorectal surgery. Secondary outcomes were need for vasopressors, extubation on table, post-operative renal functions and length of ICU (LOICU) stay. METHODS: American society of anaesthesiologists (ASA) physical status I-II patients scheduled for robot-assisted colorectal surgery were randomised into one of two groups, receiving either 2 mL/kg/h (Group R) or 4mL/kg/h, (group L). Fluid boluses of 250 ml were administered if mean arterial pressure (MAP) <65 mmHg or urine output <0.5 ml/kg/h. Norepinephrine was added for the blood pressure after 2 fluid boluses. Surgical field was assessed by modified Boezaart's scale and surgeon satisfaction by Likert scale. RESULTS: Demographics and baseline renal functions were comparable. Adjusted intra-operative lactate at 2 h, 4 h, and 6 h and need for noradrenaline and post-operative creatinine were similar. One patient in the group L was ventilated due to hypothermia. The field was better at the 4 h in group R and comparable at other time points. The LOICU stay was longer in Group L. CONCLUSION: The use of restrictive fluid strategy of 2 mL/kg/h (group R) does not increase lactate levels or creatinine, improves surgical field at 4 h and shortens ICU stay in comparison to a liberal 4 mL/kg/h (group L) in robotic colorectal surgery.

Comparison of cross-legged sitting position with the traditional sitting position for the ease of insertion of an epidural catheter in parturient for providing labour analgesia: A randomised control trial.

BACKGROUND AND AIMS: The patient's position during the insertion of the epidural catheter plays a major role in the success of labour analgesia. In our study, we compared the ease of insertion of the epidural catheter in either traditional sitting position (TSP) or crossed-legged sitting position (CLSP). The primary objective was to compare the number of successful first attempts at epidural placement between the groups. Secondary objective included patient comfort, ease of landmark palpation and the number of needle-bone contacts. METHODS: The prospective non-blinded randomised control study was conducted on 50 parturient with uncomplicated pregnancy during active labour. Patients were randomly assigned into two groups using a computer-generated random sequence of numbers by closed envelope technique. Group TSP received epidural in a traditional sitting position and group CLSP received an epidural in a crossed-legged sitting position with knee and hip flexed. RESULTS: The parturient in both groups were comparable with respect to the distribution of age, height, weight and parity. The baseline visual analogue score (VAS) and VAS scores at 15 min were comparable between groups. Percentage of a parturient with successful epidural placement in the first attempt was higher in CLSP group than in TSP group (88% versus 44%, P = 0.004). The landmark, needle-bone contact and comfort during positioning were comparable between the two groups. CONCLUSION: Cross-legged sitting position is a better position than the traditional sitting position for the ease of insertion of labour epidural catheter.