Recent advances in anaesthesia for abdominal solid organ transplantation.

Organ transplantation has undergone remarkable revolution in the last two decades and offers a scope for survival amongst patients with end-stage organ failure. Along with availability of advanced surgical equipment and haemodynamic monitors, minimally invasive surgical techniques have emerged as options for surgery both amongst the donors and recipients. Newer trends in haemodynamic monitoring and expertise in ultrasound guided fascial plane blocks have changed the management in both donors and recipients. The availability of factor concentrates and point-of-care tests for coagulation have allowed optimal and restrictive fluid management of patients. Newer immunosuppressive agents are useful in minimising rejection following transplantation. Concepts on enhanced recovery after surgery have allowed early extubation, feeding and shorter hospital stay. This review gives an overview of the recent progress in anaesthesia for organ transplantation.

Management of pregnant female with Haemophilia-A: A case report.

Haemophilia-A is a rare, X-linked recessive inherited disease affects males and females are carrier results in prolonged bleeding after minor injuries, procedures or surgery. Spontaneous or recurrent bleeding may occur in deep muscles, joints but intracranial haemorrhage can be dangerous. Women with a family history of bleeding disorder, personal history of bleeding (menorrhagia, mucous membrane, postoperative bleeding and PPH) or a prolonged activated partial thromboplastin time (aPTT) should be screened for haemophilia by measuring coagulation factor VIII level during hospital visits for these reason or antenatal care (ANC). Female heterozygote carriers may have variable presentation of bleeding due to reduced levels of clotting FVIII and may experience excessive bleeding due to gynaecologic issues, during spontaneous abortion, medical termination of pregnancy or invasive prenatal diagnostic techniques in first trimester of pregnancy, antepartum and postpartum haemorrhage in later part of gestation and after delivery.

Comparison of palonosetron and ondansetron in preventing postoperative nausea and vomiting in renal transplantation recipients: a randomized clinical trial.

BACKGROUND: End-stage renal diseases patients have a high risk of postoperative nausea and vomiting (PONV), which is multifactorial and need acute attention after renal transplantation for a successful outcome in term of an uneventful postoperative period. The study was done to compare the efficacy of palonosetron and ondansetron in preventing early and late-onset PONV in live donor renal transplantation recipients (LDRT). METHODS: The prospective randomized double-blinded study was done on 112 consecutive patients planned for live donor renal transplantation. Patients of both sexes in the age group of 18-60 years were randomly divided into two groups: Group O (Ondansetron) and Group P (Palonosetron) with 56 patients in each group by computer-generated randomization. The study drug was administered intravenously (IV) slowly over 30 seconds, one hour before extubation. Postoperatively, the patients were accessed for PONV at 6, 24, and 72 hours using the Visual Analogue Scale (VAS) nausea score and PONV intensity scale. RESULTS: The incidence of PONV in the study was found to be 30.35%. There was significant difference in incidence of PONV between Group P and Group O at 6 hours (12.5% vs. 32.1%, p = 0.013) and 72 hours (1.8% vs. 33.9%, p < 0.001), but insignificant difference at 24 hours (1.8% vs. 10.7%, p = 0.113). VAS-nausea score was significantly lower in Group P as compared to Group O at a time point of 24 hours (45.54 ± 12.64 vs. 51.96 ± 14.70, p = 0.015) and 72 hours (39.11 ± 10.32 vs. 45.7 ± 15.12, p = 0.015). CONCLUSION: Palonosetron is clinically superior to ondansetron in preventing early and delayed onset postoperative nausea and vomiting in live-related renal transplant recipients.

Emergency medicine - A great career field for the anaesthesiologist!

Emergency Medicine (EM) is a fast upcoming medical speciality wherein patients presenting with emergent life-saving medical and surgical problems are managed. Emergency physicians are first-line providers of emergency care. They diagnose important clinical conditions even before completing patient assessment, order investigations, interventions, resuscitation and treatment for life-threatening acute conditions. There are several interesting sub-specialisations of EM like trauma care, disaster medicine, toxicology, ultrasonography, critical care medicine, hyperbaric medicine, etc. In some countries, the speciality of EM is a popular choice among medical students; whereas in some other countries, the speciality is now evolving. In India, the speciality is growing fast; Nonetheless, the National Medical Commission has made the existence of the department of EM compulsory in all medical colleges in India from the session of 2022-23. Anaesthesiologists suit the speciality of EM because they have quick decision making skills and swift reflexes as well as diverse knowledge and skills in the fields of critical care, resuscitation and pain management. This article written by anaesthesiologists working in the field of EM, attempts to guide the postgraduate students wanting to take up a career in EM.

Potential Applicability of Perioperative Thromboelastography to Access the Coagulopathies in Live-Related Renal Transplantation - A Prospective Observational Pilot Study.

Ischemic and reperfusion injury (IRI) occurs during organ transplantation. IRI during liver transplantation is well studied and established; results in coagulopathy due to release of heparin-like substances and platelet trapping. During renal transplantation, similar IRI phenomenon occurs, and thromboelastography (TEG) can be used to detect and manage coagulopathy. The preoperative, immediate postreperfusion, and postoperative day 1 TEG was done on 25 cases of live-related renal transplantation. Coagulopathy was defined by deranged and abnormal TEG variables values from baseline and supported by the clinical presence of nonsurgical oozing and bleeding in the surgical field. The postreperfusion TEG values showed coagulopathic changes. About 64% of patients had R-time (RT) more than 12 min, 64% of patients showed maximum amplitude (MA) <55 mm, and 76% of patients had alpha angle <55°. The presurgical TEG clotting index (CI) was +2.45 ± 1.25, postreperfusion CI was -1.96 ± 4.54, and postoperative CI was +4.02 ± 1.35. Univariate analysis revealed that antithymocyte globulin was a significant, but etiology was closure to a significant level as protecting factor, but in multivariate analysis, both variables showed protecting factor with insignificant results. There was a weak correlation between CI with serum creatinine at all time points suggested no linear relationship between serum creatinine and corresponding CI. Hence, the results of study proves that IRI during renal transplant is associated with transient self-limiting coagulopathy, that may be early detected by TEG. CI values in postoperative 24 h apart indicating a hyper-coagulable or prothrombotic state and post-reperfusion CI values show a trend toward hypocoagulable status. No significant effect of different immunosuppression on coagulation and week correlation was found of serum creatinine level (graft function) with CI, which conclude that changes in coagulation have not affected graft function.

To compare intraoperative goal directed fluid therapy by trans-oesophageal Doppler vis-à-vis FloTrac™ in patients undergoing living related renal transplantation-a prospective randomised controlled study.

BACKGROUND: Optimal intra-operative fluid therapy in renal transplantation (RT) is essential to ensure adequate graft function while preventing fluid overload related complications. This RCT was to compare the intraoperative goal directed fluid therapy (GDFT) based either on corrected flow time (CFT), measured by trans oesophageal Doppler (TED) or on the stroke volume variation (SVV), by FloTrac in patients undergoing living donor RT. METHODS: This prospective, randomised controlled trial (RCT) was done on 60 end stage renal disease (ESRD) patients, American Society of Anaesthesiologists(ASA) grade III-IV, age 18 to 65 years of either sex, scheduled for living donor RT under general anaesthesia. They were randomly divided into two groups: TED group (n = 30) and FloTrac™ group (n = 30) and administered GDFT, based upon CFT (TED) and SVV (FloTrac™). The primary outcome was to compare the total fluid and number of fluid boluses administered intraoperatively, while the secondary outcomes were to compare any postoperative complications due to fluid overload and allograft function, assessed by serial serum creatinine levels up to 90 days postoperatively. RESULTS: The mean total intra-operative fluid [3991.67 ± 856.32 vs. 3543.33 ± 1131.35, P = 0.089] and the amount of fluid administered per kg body weight per hour [13.32 ± 4.67 vs. 11.82 ± 4.76, P = 0.222] were lesser in the FloTrac compared to TED group, though not statistically significant. However, the postoperative incidence of allograft dysfunction, including rejection (P = 0.743) and acute tubular necrosis (ATN) (P = 0.999), and other complications (P = 0.643) were comparable. CONCLUSIONS: Both TED and FloTrac devices can be used effectively to guide GDFT in RT, However, lesser total fluid was required in the FloTrac group, which may lead to a lesser number of fluid-related postoperative complications.

Efficacy of ultrasound guided quadratus lumborum block as postoperative analgesia in renal transplantation recipients: A randomised double blind clinical study.

BACKGROUND AND AIMS: Postoperative pain following renal transplantation is moderate to severe. Quadratus lumborum block (QLB) is a new block that can provide effective analgesia following abdominal and retroperitoneal surgeries. This study aimed to evaluate the analgesic efficacy of QLB for postoperative analgesia in patients undergoing renal transplantation. METHODS: Patients were randomised into two groups of 30 each. In group A (block group), 20 mL of 0.25% bupivacaine and group B (placebo group), 20 mLof normal saline were injected. In the postoperative room, an intravenous patient controlled analgesia (IVPCA) pump with fentanyl was started in both the group. The postoperatively recorded parameters were numerical rating scale (NRS) pain score at rest and on movement and coughing, total fentanyl consumption, sedation score, postoperative nausea vomiting, limb weakness, paralytic ileus, and any other block-related complication. Data were analysed using SPSS software version 22.0. Categorical data were analysed using the Chi-square method. Student t test or Mann-Whitney U test was applied for the continuous data. Numerical data with normal distribution were displayed as mean (standard deviation), abnormal distribution was displayed in the median (interquartile range) values, and as a percentage for categorical variables. RESULTS: Fentanyl consumption, numerical rating score, and sedation score were significantly less in group A when compared to group B at 1, 4, 8, 12, and 24 h (P < 0.001). CONCLUSION: Type-1 QLB significantly reduces fentanyl consumption and NRS pain score at 1,4,8,12, and 24 h in the postoperative period in renal transplant recipients.

Ultrasound-guided Anterior Quadratus Lumborum Block for Postoperative Pain after Laparoscopic Pyeloplasty: A Randomized Controlled Trial.

BACKGROUND: Quadratus lumborum block (QLB) has provided adequate analgesia and lowered postoperative opioid requirement in comparison to controls for some urological surgeries. AIMS: The aim of this study was to assess the efficacy of postprocedure ultrasound-guided QLB in comparison to port-site infiltrations with local anesthetics (as control) in lowering postoperative pain after laparoscopic pyeloplasty. SETTINGS AND DESIGN: This was a prospective, single-blinded, randomized controlled trial. MATERIALS AND METHODS: Fifty-three adults undergoing laparoscopic pyeloplasty were randomly allocated to either anterior QLB group (n = 27) or port-site infiltration Group P (n = 26) with 20 mL of 0.5% ropivacaine. The primary outcomes were static and dynamic pain on the Visual Analog Scale (VAS) of 0-100 at the 30th min, 2nd, 6th, 12th, and 24th hour after surgery. The secondary outcomes were number of patients requiring rescue analgesics and having postoperative nausea or vomiting (PONV) in 24 hours after surgery. STATISTICAL ANALYSIS: Intergroup comparison of VAS was done with Student's t-test. Categorical data were analyzed using the Chi-square test. RESULTS: The static VAS scores were found to be significantly lower in QLB group at the 2nd, 6th, and 12th hour, and the dynamic VAS was lower at all time points after the 30th min in the QLB group. The number of patients requiring rescue analgesics were significantly lower in the QLB group (13 as compared to 21 in Group P; P = 0.015). The incidence of PONV was comparable. No other side effects were seen. CONCLUSION: Ultrasound-guided anterior QLB is more effective in comparison to traditional technique of port-site local anesthetic infiltration for providing analgesia after laparoscopic pyeloplasty.

Efficacy of Double Drug Impregnated Autologous Coagulum Patch versus Single Drug Impregnated Autologous Coagulum Patch in Postoperative Pain Management after Spinal Surgery.

BACKGROUND: Postoperative pain and cerebrospinal fluid (CSF) leak are common known complications of spinal surgery, both having a synergistic effect on each other. Thus, both need to be dealt simultaneously. Double drug impregnated autologous coagulum patch (DDIAC) is a novel method which reduced both incidences of postoperative CSF leaks as well as pain. METHODOLOGY: Twenty-seven patients undergoing lumbar disc surgery without instrumentation were included and randomized into DDIAC and single drug impregnated autologous coagulum patch (SDIAC) group. The patients were assessed postoperatively with visual analog scale (VAS). RESULTS: There were 21 males and 6 females in the study. Seventeen (63%) patients got randomized for DDIAC patch application and other 10 (37%) patients entered the control arm group (SDIAC) patch use. Preoperative VAS was 5 in both the groups. The average postoperative VAS was 3.01 in DDIAC arm and 4.29 in control arm. The average analgesic shot required in the DDIAC group was 0.41 in 24 h and SDIAC group was 4.1 in 24 h. In DDIAC group, none of these patients had CSF leak from the surgical wound till discharge from the hospital. In the SDIAC group, one (10%, n = 10) patient had CSF leak. CONCLUSIONS: DDIAC patch was effective in controlling pain in the postoperative period; however, few patients may require analgesic shots for pain management. SDIAC patch may control some pain in the immediate postoperative period; however, this was not sufficient for a longer postoperative period.

Dexmedetomidine for prevention of early postoperative catheter-related bladder discomfort in voluntary kidney donors: Prospective, randomized, double-blind, placebo-controlled trial.

BACKGROUND AND AIMS: Catheter-related bladder discomfort (CRBD) has started to gain recognition as a problem in early postoperative care. Dexmedetomidine reduces bladder contractility via M3 muscarinic receptor antagonism and α-2 receptor agonism, apart from its concomitant therapeutic benefits, such as sedation and sympatholysis, in a postoperative period. We, therefore, evaluated the efficacy of dexmedetomidine in reducing incidence and severity of CRBD. MATERIAL AND METHODS: This prospective, randomized, double-blind, placebo-controlled trial done on 110 voluntary kidney donors for live related kidney transplantations were planned for laparoscopic donor nephrectomy. The donors were of ages 18-60 years, American Society of Anesthesiologists physical status I and II of either sex. The control group received 20 ml normal saline (NS) intravenous (IV) infusion over 15 min, whereas the dexmedetomidine group received dexmedetomidine 1 µg/kg made in 20 ml NS as IV infusion over 15 min. The incidence and severity of CRBD were recorded as primary endpoints up to 12 h in early postoperative period. The incidence of bladder discomfort was analysed by Fisher's exact test and severity of bladder discomfort by Mann Whitney U test. RESULTS: The incidence of CRBD on arrival at postoperative care unit was 18% in dexmedetomidine group compared to 42% in control group (P < 0.05). The incidence and severity of CRBD reduced in dexmedetomidine group at 0, 2, and 4 h compared with control group (P < 0.05). CONCLUSIONS: Dexmedetomidine 1 µg/kg administered IV to patients 30 min before extubation reduces the incidence and severity of CRBD in early postoperative settings with no adverse effects.

A Novel and Innovative Way of Nasogastric Tube Insertion in Anesthetized Intubated Patient.

Nasogastric tube (NGT) placement in anesthetized and intubated is sometimes very challenging with more than 50% failure rate in the first attempt. We describe a newer innovative Sahu's three in one, technique with use of GlideScope and forward placement of intubated trachea by external laryngeal maneuver, these both techniques lead to separation of trachea from esophagus so that endoscopic jejunal feeding tube guide wire strengthen NGT can be guided and manipulated to esophagus under direct vision. After informed consent, we used Sahu's three in one combo technique to insert NGT in adult anesthetized and intubated patients of both the sexes with high success in the first attempt. We found this technique easy, helpful, less time consuming with high success rate.