Ultrasound-guided pericapsular nerve block compared with IV opioids in hip injuries: A randomised controlled trial.

STUDY OBJECTIVES: The study aimed to compare the analgesic effect of USG-guided PENG (Peri capsular nerve group) block with Intravenous Nalbuphine hydrochloride (IVN) in patients with hip fracture coming to the emergency department (ED). The purpose was also to monitor the adverse effects and rescue analgesic requirements in both treatment modalities. METHODS: The study was an open-label randomised controlled trial (RCT) comparing PENG block versus IVN in treating patients with femoral head and neck fractures, as well as pubic rami fracture of the hip (HF). The participants in the PENG group received a USG-guided PENG block by injection of 25 ml of 0.25% bupivacaine, whereas the IVN group received 0.15 mg/kg of nalbuphine. An emergency physician with expertise in ultrasound-guided nerve blocks performed the PENG blocks. The primary outcome was to measure the improvement of the NRS (Numerical rating scale) score at 30 min in both static position (Patient-chosen position for the best comfort) and dynamic position (15-degree passive affected lower limb elevation). Secondary outcomes were to measure static and dynamic NRS pain scores at 2 h, 4 h, and 6 h after intervention in both groups. The requirement for rescue analgesia, adverse events and any block-related complications were also recorded. RESULTS: A total of 60 patients with HF were included in the final analysis. The static and dynamic NRS score was significantly lower in the PENG group compared to the IVN group at 30 min, 2 h, 4 h, and 6 h post-intervention. In the PENG group, the static NRS score was improved by 5.73 ± 1.17, while In the IVN group, the static NRS score was just improved by 2.13 ± 0.97 at 30 min. In the same duration, the Dynamic NRS score in the PENG group was improved by 6.13 ± 1.38, while In the IVN group, it improved just by 2.43 ± 1.28. Rescue analgesia was required in 50.0% of patients in the IVN group but none in the PENG group. Further, no block-related complications or adverse events were observed in the patients of the PENG group. CONCLUSION: The study provides evidence that the ultrasound-guided PENG block has a better analgesic effect and has fewer adverse events than IV opioids in patients with HF.

Radial artery duplication: Unusual point-of-care-ultrasonography finding during arterial cannulation.

The radial artery is the most common choice for arterial cannulation, coronary interventions, and various interventional radiological procedures. Here, we describe a case of unilateral duplication of the radial artery detected during radial artery cannulation using point-of-care ultrasonography (POCUS). The duplication of the radial artery in the forearm can hinder trans-radial access secondary to variations in the diameter. An actual duplication also carries a high risk of accidental injury to the arterial wall during routine invasive procedures and other forearm procedures such as free flap construction. POCUS is invaluable for detecting arterial anomalies before proceeding with any interventional procedures.

Ultrasound-guided selective peripheral nerve block compared with the sub-dissociative dose of ketamine for analgesia in patients with extremity injuries.

STUDY OBJECTIVE: To compare the analgesic efficacy of ultrasound-guided selective peripheral nerve block (PNB) and sub-dissociative dose ketamine (SDK) for management of acute pain in patients with extremity injuries presenting to the emergency department (ED). METHODS: This prospective, open-label randomized clinical trial was conducted in the ED of a tertiary care Institute. The patients were provided with either ultrasound-guided selective PNB or SDK. The primary outcome was a reduction in pain in numerical rating scale (NRS) by at least 3 points without rescue analgesia. The secondary outcomes were the need for rescue analgesia, adverse events, and patient satisfaction on either arm. RESULTS: A total of 111 patients with isolated traumatic extremity injuries were included in the final analysis. The NRS score was significantly lower in the PNB group compared to the SDK group at 30, 60,120, 180-, and 240-min post-intervention [group ∼ time interaction, F (5, 647) = 21.53, p ≤ 0.001]. All the patients in the PNB group exhibited primary outcome (NRS ≥3 reductions) at 30 min post-intervention compared with 36 (65%) in the SDK group [-1.02(-1.422,0.622)]. Rescue analgesia was required in 10 (18%) patients in the SDK group compared to none in the PNB group [0.663(0.277,1.050)]. The decrease in NRS score from baseline at 30 min was significantly higher in PNB groups compared to the SDK group [-2.166(-2.640, -1.692)]. The most common side effect reported in the SDK group was dizziness 35(64%), followed by nausea 15(27%). None of the patients in the PNB group reported any complications. Patient satisfaction was higher in the PNB group than SDK group. CONCLUSION: The study provides evidence that ultrasound-guided PNB is superior to SDK in terms of its analgesic efficacy in the management of acute pain due to extremity injuries and is associated with higher patient satisfaction. The need for rescue analgesia was significantly less in the PNB group. SDK was associated with a high incidence of dizziness and nausea.

Complications and Difficulties Encountered in the Management of a Neglected Osteoporotic Proximal Humerus Fracture.

Introduction: Osteoporosis is a known complication of prolonged steroid therapy. Osteoporotic fracture is common in such a scenario and poses several challenges in its management. We present a case of neglected proximal humerus fracture in a 57-year-old osteoporotic female and the difficulties encountered in its management. Case Report: A 57- year-old female, rheumatoid arthritis patient, is on steroids for the past ten years. Four years back, she sustained a fracture of the left humerus neck following a trivial trauma. The fracture was not managed by an orthopaedician and was treated by a general practitioner. She presented to us in a state of painless displaced non-union of fragments with severe osteoporosis. DEXA scan revealed severe osteoporosis. She was started on oral calcium, magnesium, and vitamin D supplementation. Along with oral supplementation, the patient was advised 20 mcg of Teriparatide subcutaneously once daily and single dose of Denosumab 60 mg subcutaneously. Non -vascularized free fibular graft was harvested from the ipsilateral lower limb. A five-hole PHILOS plate was used to fix the fracture. Intra-operatively, the humeral head appeared too indistinct under fluoroscopy leading to difficulty in estimating screw length. An indirect method was used to assess the screw length. The post-operative radiograph was satisfactory but radiograph after two weeks showed an un-displaced fracture adjacent to the distal end of the plate. It was decided to continue with conservative management by a "'U"' cast. A follow- up radiograph at three months showed complete union of the stress fracture at the distal end of the plate end and progressive union of the fracture at the primary site. But En- block pull-out of the locking plate was noticed in the distal fragment of the fracture in the follow-up radiograph at 9 months from surgery. The limb was further immobilized in an arm sling for more four weeks. At one year from operation, there was good union of fracture with acceptable shoulder movement. Conclusion: Osteoporotic fractures are often difficult to treat. Careful pre-operative planning, active osteoporosis management, good implant selection, careful bone handling, and judicious rehabilitation are key to avoid complications and achieve good functional outcome.

Influence of 3% Hypertonic Saline Versus 0.9% Saline on Intraoperative Maintenance Fluid Requirements in Adult Patients Undergoing Major Open Abdominal Surgeries: Randomized Controlled Study.

BACKGROUND: Three percent hypertonic saline (3% HTS) acts like an osmotic buffer and draws fluid from the extracellular space into the intravascular compartment. Primary objective was to evaluate whether use of 3% HTS resulted in a difference in intraoperative maintenance fluid requirement versus 0.9% saline (NS). Secondary objectives were to evaluate differences in 24 h fluid requirements and safety of 3% HTS. METHODS: Adult patients of either sex, 18-65 years, undergoing elective major open abdominal surgeries were randomized to receive infusions of 3% HTS or NS at 1 ml/kg/hr through large bore peripheral i.v cannulas, or central venous catheters after anesthesia induction. Intraoperative maintenance fluids were administered to maintain mean arterial pressure (≥70 mmHg), urine output (≥0.5 ml/kg/hr) and central venous pressure of 8-10 cm H2O. RESULTS: Ninety-three patients completed the study (46 in 3% HTS and 47 in NS group). No difference was seen in the volume of intraoperative maintenance fluids (3% HTS vs NS; 2243.9 ± 896.7 ml vs 2093.6 ± 868.7 ml; P = 0.34). Similarly, the 24 h postoperative fluid requirement was not different (3% HTS vs NS; 2006.6 ± 398.6 ml vs 2018.3 ± 389.3 ml; P = 0.94). Patients in 3% HTS group had statistically but not clinically significant higher serum sodium values at postoperative 12th and 24 h. No complication like thrombophlebitis or tissue ischemia was reported due to administration of 3% HTS through peripheral lines. CONCLUSION: Administration of 3% HTS did not reduce intraoperative maintenance fluid requirements in patients undergoing major open abdominal surgeries. TRIAL REGISTRATION: CTRI/2019/09/021032.