Post-COVID-19 Pulmonary Fibrosis: A Lifesaving Challenge.

How to cite this article: Prakash J, Bhattacharya PK, Priye S, Kumar N. Post-COVID-19 Pulmonary Fibrosis: A Lifesaving Challenge. Indian J Crit Care Med 2021;25(1):104-105.

Prevention of propofol injection pain: Comparison between lidocaine and ramosetron.

BACKGROUND: Propofol causes a high incidence of pain during intravenous (IV) injection. The aim of this randomized, placebo-controlled, double-blinded study was to determine whether pre-treatment with IV ramosetron, used for prophylaxis of postoperative nausea and vomiting (PONV), would reduce propofol-induced pain as an equivalent to lidocaine. MATERIALS AND METHODS: Hundred and twenty American Society of Anesthesiologists grade (ASA) I and II patients were randomly assigned into three groups (40 in each). Group N received 2 ml of 0.9% saline, Group L received 2 ml of lidocaine, and Group R received 2 ml of ramosetron. Mid forearm was occluded manually before injection and released after 1 min and then propofol was injected over 5 s. Patients were observed and questioned 15 s later if they had pain in the arm and pain was scored on a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain. Unpaired Student's t-test and chi-square test/Fisher' exact test were used to analyze results. RESULTS: The incidence of pain in groups N, L, and R were 65, 35, and 30%, respectively. Pain was reduced significantly in the groups L and R (P < 0.05). Two patients each in Groups L and R (5% each) had moderate and severe pain. This difference in pain was statistically insignificant, but when compared to Group N (25 and 30%, respectively) it was statistically significant. CONCLUSION: Pretreatment with ramosetron 0.3 mg and lidocaine 40 mg are equally effective in preventing pain from propofol injection.

Comparative Study of Levobupivacaine Versus Levobupivacaine With Dexmedetomidine as an Adjuvant in Transversus Abdominis Block for Postoperative Pain Relief in Abdominal Hysterectomy Patients: A Randomized, Double-Blind Study.

Background Adjuvants have been discovered to prolong the analgesic impact of local anesthetics (LA), while the transversus abdominis plane (TAP) block offers sufficient postoperative pain relief after various abdominal procedures. Nevertheless, the impact of the given LA will determine the duration of the TAP block. Thus, in this investigation, we aimed to estimate the analgesic impact of combining dexmedetomidine (DEX) with levobupivacaine in the TAP block for patients having an infraumbilical incision for an abdominal hysterectomy while under spinal anesthetic. Aim This study aimed to determine the analgesic effect of DEX (0.5 mcg/kg) to 20 ml of 0.25% levobupivacaine on each side in the TAP block in patients undergoing total abdominal hysterectomy (TAH). Materials and methods Two groups of 30 patients each, with ASA grades 1 and 2, were randomly selected from patients. Group N, comprising 30 patients, had a bilateral TAP block using 2 mL of normal saline and 20 mL of 0.25% levobupivacaine. Group D (n = 30 patients) was given DEX at a dose of 0.5 mcg/kg (2 mL) in addition to 20 mL of 0.25% levobupivacaine given bilaterally. The TAP block was administered just after skin closure. Time of the initial analgesic dose administration; total fentanyl doses utilized as rescue analgesia; pain scores (numerical rating scale (NRS)) at 2, 4, 6, 8, 12, and 24 hours; and pre- and postoperative cortisol levels were also noted. For each group, 1 gram IV paracetamol was administered every eight hours. Drugs used for rescue analgesia (RA) were diclofenac 75 mg IV stat and fentanyl 1 mcg/kg. Results and discussion In addition to Group N having lower NRS scores at rest, Group D had a considerably longer time for initial rescue analgesia than Group N. There was also a significant decrease in the total fentanyl consumption and postoperative serum cortisol levels in Group D in contrast to Group N. Conclusion Potential adjuvant DEX prolongs postoperative analgesia in patients experiencing abdominal hysterectomy when used alongside LA in TAP.

Preemptive Levetiracetam Decreases Postoperative Pain: A Double-Blind, Randomised, Control Trial.

Background Previously many studies have found the use of anti-epileptic drugs such as pregabalin, carbamazepine, and gabapentin in pain management. In addition, levetiracetam (LEV), an effective anti-epileptic drug, has shown analgesic effects in animal models. We aimed to evaluate the effect of oral LEV as pre-emptive analgesia in patients who underwent laparoscopic cholecystectomy under general anaesthesia and postoperative fentanyl requirements. Material and methods Forty-two patients of the American Society of Anaesthesiologists (ASA) grade I and II of either gender posted for elective laparoscopic cholecystectomy surgery were included in this double-blind, randomised, placebo-controlled study. Patients were divided into two equal groups of 21 each to receive either tablet LEV 500 mg or a matching placebo tablet, given 1 hour before surgery. Postoperative pain was assessed by a visual analogue scale (0-100 mm), where 0 meant no pain and 100, worst pain. In addition, patients received IV fentanyl as rescue analgesia during the first 24 hours of the postoperative period. Results Nineteen patients in the LEV group and 20 in the placebo group completed the study. Patients in the LEV group had significantly lower pain scores at all time intervals except 0 hours and reduced fentanyl consumption postoperatively in the first 24 hours (p<0.05). Side effects were comparable in both groups. Conclusion A single, preoperative dose of oral LEV 500 mg significantly decreases post-surgical pain and fentanyl demand as rescue analgesia in elective laparoscopic cholecystectomy.

Comparison of analgesic effects of pericapsular nerve group block and fascia iliaca compartment block during hip arthroplasty: A systematic review and meta-analysis of randomised controlled trials.

Background and Aims: Postoperative pain for patients having hip arthroplasty ranges from moderate to severe. Many regional anaesthesia procedures treat postoperative pain to improve functional ability and quality of life. Evidence comparing the analgesic effects of the pericapsular nerve group (PENG) block and fascia iliaca compartment block (FICB) remains unclear. The analgesic efficacies of PENG and FICB in hip arthroplasty were compared to determine which technique is associated with superior analgesia. Methods: The electronic databases (PubMed, Cochrane Library, Google Scholar and Web of Sciences) were searched for published randomised controlled trials (RCTs) till 5 April 2023 comparing PENG block vs. FICB following hip arthroplasty. The primary outcome was pain scores [numerical rating scale (NRS) or visual analogue scale (VAS)] between 0 and 10 at rest and during movement at 24 h. Secondary outcomes included pain scores at rest and during movement within 30 min, at 6 h and 12 h, time to first rescue analgesia and cumulative postoperative opioid use in 24 h. We assessed the risk of bias using the Cochrane Collaboration Risk-of-Bias 2 tool. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE), the certainty of the evidence was assessed. Subgroup analysis was performed to explore the source of heterogeneity. Results: We included 12 RCTs examining 644 patients. Pain scores at rest at 24 h (standardised mean differences (SMDs): 0.17; 95% confidence interval (CI): -0.90 to 1.23; P = 0.76, moderate certainty) and during movement at 24 h (SMD: -0.58, 95% CI: -1.53 to 0.38, P = 0.24, moderate certainty) were not different in both PENG block and FICB. Pain scores at rest and during movement within 30 min may be lower with PENG block than FICB. However, the pain score at rest and during movement at 6 h and the time to first rescue analgesia were not different between the two treatment arms. The mean opioid consumption in oral morphine equivalents (mg) in 24 h may be lower with PENG than FICB. Conclusion: We observed no difference between the PENG block and the FICB at 24 h for pain at rest and movement with a moderate degree of certainty. However, PENG block showed improved analgesia within 30 min at rest and during movement, and reduce postoperative opioid consumption in 24 h with moderate certainty of evidence. Further large-scale and high-quality RCTs are required to supplement the present findings.

Effects of Epidural Analgesia on Labor Pain and Course of Labor in Primigravid Parturients: A Prospective Non-randomized Comparative Study.

BACKGROUND AND AIM:  The aim of this study was to compare the effects of epidural analgesia on relief of labor pain, progress, and outcome of labor in primigravid parturients to those who did not receive any analgesia. METHODS: This was a hospital-based, quasi-experimental study conducted on 70 primigravid parturients at term with a single fetus in a cephalic presentation in active labor. Parturients who were willing to receive epidural analgesia formed group S (n=35) and parturients who refused epidural analgesia formed group C (n=35). The primary objective was to compare alleviation of pain measured by the Visual Analogue Scale (VAS) score. Secondary objectives were to compare the duration of labor, mode of delivery, and neonatal outcome. RESULTS: Pain intensity was significantly lower in group S compared to group C at all measured points of time (p<0.001). There was a quick fall in mean VAS score in group S from 7.94 to 3.86 within 20 min with the bolus dose, it further dropped to 1.03 after 3 h. Further, 88.6% of parturients in groups rated their pain relief as excellent and good satisfaction score. Prolongation of active phase of the first stage of labor (>6 h) was not significant (17.1 % in epidural group versus 5.7% in control group; p=0.259). However, prolongation of the second stage of labor (> 2h) was significant (18.2% in study group versus 0% in control group; p=0.024). The rate of cesarean section, instrumental vaginal delivery, and neonatal outcome was similar in both groups. No adverse effects were observed on maternal vitals, fetal heart rate and Apgar score at 5 min. CONCLUSION:  Epidural analgesia alleviated labor pain in all primigravid parturients who opted for it, without an increase in cesarean section and instrumental vaginal birth. Improved parturients' satisfaction with associated neonatal safety provides a positive birth experience. There was no effect on duration of active phase of the first stage of labor, but the duration of the second stage of labor was slightly prolonged.

Morphine-Induced Fever: A Case Series.

The most common cause of postoperative fever is infection. Other causes include cancer, iatrogenic causes, venous thromboembolism, secondary to prosthetic implants, and pyrexia of unknown origin. Here, we describe five cases of opioid-induced pyrexia. In all cases, an injection of morphine was given for postoperative analgesia and all those patients developed fever. All the possible causes of fever were excluded and then opioid was substituted with non-steroidal anti-inflammatory agents. Fever subsided in all the cases. Cessation of the offending drug led to the resolution of the fever in all five cases, and the patient required subsequent supportive care. However, adjunctive pharmacotherapy may also be needed in some patients.

Ultrasound Guided Measurement of Anterior Neck Tissue for the Prediction of Difficult Airway: A Prospective Observational Study.

Objectives: To determine that ultrasound (US) measurements of anterior neck soft tissue thickness at hyoid bone, thyrohyoid membrane, and anterior commissure levels can be used to predict difficult laryngoscopy. Materials & Methods: The present study included 100 patients of age group 18-60 years undergoing elective surgery under general anaesthesia. It was a prospective observational study which included patients with ASA physical status I and II. Excluded patients were with facial and neck deformities, neck trauma, or those undergoing surgery of the larynx, epiglottis and pharynx. Comparison analysis was performed using t-test for continuous variables and chi-square or Fisher exact test for non-continuous variables. Correlation analysis performed using Pearson test. Results: There were 39 out of 100 patients categorised as difficult laryngoscopy. Thickness at hyoid bone (DSHB), thyrohyoid membrane (DSEM) and anterior commissure (DSAC), MMS (modified Mallampati score), and BMI (body mass index) were greater in the difficult laryngoscopy group (p < 0.001). TMD (thyromental distance) was less in the difficult laryngoscopy group (p < 0.001). There was a strong positive correlation between DSEM and DSAC (r = 0.784). Moderate positive correlation was between DSEM and DSHB (r = 0.559), DSEM and MMS(r=0.437). The area under curve (AUC) of DSHB, DSEM, DSAC, TMD and MMS is >0.7. The optimal cut-off values for DSEM, DSHB, DSAC and TMD were 1.34 cm, 0.98 cm, 1.68 cm and 6.59 cm, respectively, in predicting difficult airway. Conclusion: Ultrasound measurement of soft tissue thickness at hyoid bone, thyrohyoid membrane, and anterior commissure of vocal cord are good independent predictors for difficult laryngoscopy. When combined with traditional screening tests it improves the ability to predict difficult laryngoscopy.

Comparison of Perineural and Intravenous Dexamethasone as an Adjuvant to Levobupivacaine in Ultrasound-Guided Infraclavicular Brachial Plexus Block: A prospective Randomized Trial.

BACKGROUND: The effect of perineural versus intravenous (i.v.) dexamethasone (4 mg) when added to levobupivacaine as an adjuvant has not been well studied. AIMS: This study was conducted to compare the analgesic efficacy of perineural and i.v. dexamethasone as an adjuvant to levobupivacaine in infraclavicular brachial plexus (ICBP) block. SETTINGS AND DESIGN: This was a prospective, randomized, double-blind study. MATERIALS AND METHODS: This study was conducted on 68 patients with the ultrasound-guided ICBP block, randomly allocated into two groups (34 each). Four patients had failed block (2 in each group) that was excluded from the study. Group A received 25 mL of levobupivacaine 0.5% and 1 mL of normal saline for the block and i.v. dexamethasone 4 mg. Group B received 25 mL of levobupivacaine 0.5% with 4 mg of perineural dexamethasone for the block. Postoperative vitals and different block characteristics were assessed. STATISTICAL ANALYSIS USED: Student's independent sample t-test and Chi-square test were used for statistical analysis. RESULTS: The duration of motor block and analgesia in Group A was 1245.94 ± 153.22 min and 1310.16 ± 151.68 min, respectively. However, in Group B, the duration of motor block and analgesia was 1768.13 ± 309.86 min and 1743.59 ± 231.39 min, respectively, which was more when compared to Group A (P < 0.001). The Visual Analog Scale score of ≥3 in Group A was 37% and in Group B was 9% (P = 0.008). Four cases had delayed regression of motor block in the perineural group. CONCLUSIONS: Perineural dexamethasone significantly prolonged the duration of motor block promoted by levobupivacaine in infraclavicular brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period when compared with the intravenous dexamethasone.

Randomized Double-Blinded Comparative Study of Intravenous Nalbuphine and Tramadol for the Treatment of Postspinal Anesthesia Shivering.

CONTEXT: Shivering is one of the most commonly recognized complications of the central neuraxial blockade. For optimal perioperative care, control of postspinal anesthesia shivering is essential. AIMS: The present study designed to compare the clinical efficacy, hemodynamic parameters, and side effects of nalbuphine and tramadol for control of postspinal anesthesia shivering. SETTINGS AND DESIGN: This was a prospective, randomized, double-blind study. MATERIALS AND METHODS: This study was conducted on 90 American Society of Anesthesiologists Physical Status I and II patients of either gender, aged between 18 and 60 years, who subsequently developed shivering grade 3 or 4, scheduled for different surgical procedures under spinal anesthesia. The patients were randomized into two groups of 45 patients each to receive either nalbuphine 0.06 mg.kg-1 (Group N) or tramadol 1 mg.kg-1 (Group T). Grade of shivering, onset of shivering, time interval for cessation of shivering, response rate at 5 and 30 min, rescue dose, hemodynamic parameters, and side effects were observed at scheduled intervals. STATISTICAL ANALYSIS USED: Independent t-test and Chi-square/Fisher's exact test were used to analyze the data. RESULTS: The time taken for cessation of shivering was significantly less with nalbuphine in comparison with tramadol (P < 0.05). It was observed that the response time at 5 and 30 min and rescue dose requirement for control of shivering were not much difference (P > 0.05). CONCLUSIONS: Both nalbuphine and tramadol are effective; however, the time taken for cessation of shivering is significantly less with nalbuphine when compared to tramadol. Furthermore, tramadol causes significantly more nausea and vomiting; however, nalbuphine causes significantly more sedation.

The comparison of dexmedetomidine, esmolol, and combination of dexmedetomidine with esmolol for attenuation of sympathomimetic response to laryngoscopy and intubation in patients undergoing coronary artery bypass grafting.

Background: The aim of this study was to compare the effects of dexmedetomidine, esmolol, and combination of both on control of sympathetic response to laryngoscopy and tracheal intubation in coronary artery disease patients. Material and Methods: A prospective, randomized, double-blinded clinical study included 90 patients scheduled for elective coronary artery bypass surgery. Patients were randomly allocated into three groups of 30 each: dexmedetomidine group (Group D) 1 µg/kg, esmolol group (Group E) 2 mg/kg, and group dexmedetomidine with esmolol (Group DE) 0.5 µg/kg of dexmedetomidine with 1 mg/kg of esmolol. Each drug was diluted with 0.9% normal saline to 20 ml volume and infused in 10 min before induction of anesthesia. Hemodynamic changes (heart rate [HR], arterial blood pressure, and pulmonary artery pressure) were compared at various time intervals as follows-baseline, after study drug, after induction, and 1, 3, and 5 min after intubation. Statistical analysis included analysis of variance, Chi-square, and Fisher's exact test. Results: In Group DE, there was no significant increase in HR at all-time intervals, and the HR was stable compared to Group D and Group E. Blood pressure values were comparable in all groups except in Group E at 5 min. The pulmonary arterial pressures were statistically less in DE group except at 3 and 5 min. Conclusions: The combination of dexmedetomidine and esmolol group has beneficial effect on HR and pulmonary arterial pressures but has no additional advantage with respect to arterial blood pressure when compared with dexmedetomidine and esmolol groups in patients undergoing elective coronary artery bypass grafting.

Efficacy of methylprednisolone and lignocaine on propofol injection pain: A randomised, double-blind, prospective study in adult cardiac surgical patients.

BACKGROUND AND AIMS: Propofol (2, 6-di-isopropylphenol) used for the induction of anaesthesia often causes mild to severe pain or discomfort on injection. We designed this double-blind study to compare the efficacy of methylprednisolone and lignocaine in reducing the pain of propofol injection in patients scheduled for cardiac surgery. METHODS: A total of 165 adult patients, scheduled for elective cardiac surgery, were divided into three groups: saline (group S, n = 55), lignocaine 20 mg (Group L, n = 55) and methylprednisolone 125 mg diluted into 2 ml of distilled water (Group MP, n = 55). Drugs were administered after tourniquet application and occlusion was released after 1 min and 1/4th of the total dose of propofol (2 mg/kg) was administered at the rate of 0.5 ml/s. Pain on propofol injection was evaluated by four-point verbal rating scale. Statistical methods used included Student's t-test and Chi-square test/Fisher's exact test. RESULTS: The overall incidence of pain was 70.9% in the saline group, 30.9% in the lignocaine group and 36.4% in the methylprednisolone group. The intensity of pain was significantly less in patients receiving methylprednisolone and lignocaine than those receiving saline (P < 0.012). CONCLUSION: Pre-treatment with intravenous methylprednisolone was found to be as effective as lignocaine in reducing propofol injection-induced pain.

Perioperative management of patient with Bombay blood group undergoing mitral valve replacement.

Bombay red blood cell phenotype is an extremely rare blood type for which patients can receive only autologous or Bombay phenotype red blood cells. We report a case of stenotic mitral valve with Bombay phenotype who underwent minimal invasive right lateral thoracotomy for the replacement of the mitral valve. A male patient from Bangladesh presented to the hospital with New York Heart Association III symptoms. His medical evaluation revealed severe mitral valve stenosis and mild aortic valve regurgitation. The patient received erythropoietin, intravenous iron succinate and folic acid tablets. Autologous blood transfusion was carried out. The mitral valve was replaced with a prosthetic valve successfully. After weaning off from cardiopulmonary bypass, heparinisation was corrected with protamine. Post-operatively, the patient received autologous red blood cells. The patient recovered after 1-day of inotropic support with adrenaline and milrinone, and diuretics and was discharged on the 5(th) post-operative day.

Dexmedetomidine as an adjunct in postoperative analgesia following cardiac surgery: A randomized, double-blind study.

OBJECTIVES: The purpose of this study was to determine analgesic efficacy of dexmedetomidine used as a continuous infusion without loading dose in postcardiac surgery patients. SETTINGS AND DESIGN: A prospective, randomized, double-blind clinical study in a single tertiary care hospital on patients posted for elective cardiac surgery under cardiopulmonary bypass. INTERVENTIONS: Sixty-four patients who underwent elective cardiac surgery under general anesthesia were shifted to intensive care unit (ICU) and randomly divided into two groups. Group A (n = 32) received a 12 h infusion of normal saline and group B (n = 32) received a 12 h infusion of dexmedetomidine 0.4 µg/kg/h. Postoperative pain was managed with bolus intravenous fentanyl. Total fentanyl consumption, hemodynamic monitoring, Visual Analogue Scale (VAS) pain ratings, Ramsay Sedation Scale were charted every 6(th) hourly for 24 h postoperatively and followed-up till recovery from ICU. Student's t-test, Chi-square/Fisher's exact test has been used to find the significance of study parameters between the groups. RESULTS: Dexmedetomidine treated patients had significantly less VAS score at each level (P < 0.001). Total fentanyl consumption in dexmedetomidine group was 128.13 ± 35.78 µg versus 201.56 ± 36.99 µg in saline group (P < 0.001). A statistically significant but clinically unimportant sedation was noted at 6 and 12 h (P < 0.001, and P = 0.046 respectively). Incidence of delirium was less in dexmedetomidine group (P = 0.086+). Hemodynamic parameters were statistically insignificant. CONCLUSIONS: Dexmedetomidine infusion even without loading dose provides safe, effective adjunct analgesia, reduces narcotic consumption, and showed a reduced trend of delirium incidence without undesirable hemodynamic effects in the cardiac surgery patients.

Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy.

PURPOSE: To evaluate the comparative preemptive effects of gabapentin and tramadol on postoperative pain and fentanyl requirement in laparoscopic cholecystectomy. METHODS: Four hundred fifty-nine ASA I and II patients were randomly assigned to receive 300 mg gabapentin, 100 mg tramadol or placebo in a double-blind manner two hours before laparoscopic cholecystectomy under general anesthesia. Postoperatively, patients' pain scores were recorded on a visual analogue scale every two hours for the initial 12 hr and thereafter every three hours for the next 12 hr. Patients received fentanyl 2 micro g*kg(-1) intravenously on demand. The total fentanyl consumption for each patient was recorded. RESULTS: Patients in the gabapentin group had significantly lower pain scores at all time intervals (2.65 +/- 3.00, 1.99 +/- 1.48, 1.40 +/- 0.95, 0.65 +/- 0.61) in comparison to tramadol (2.97 +/- 2.35, 2.37 +/- 1.45, 1.89 +/- 1.16, 0.87 +/- 0.50) and placebo (5.53 +/- 2.22, 3.33 +/- 1.37, 2.41 +/- 1.19, 1.19 +/- 0.56). Significantly less fentanyl was consumed in the gabapentin group (221.16 +/- 52.39 micro g) than in the tramadol (269.60 +/- 44.17 micro g) and placebo groups (355.86 +/- 42.04 micro g; P < 0.05). Sedation (33.98%), nausea/retching/vomiting (24.8%) were the commonest side effects in the gabapentin group whereas respiratory depression (3.9%) was the commonest in the tramadol group and vertigo (7.8%) in the placebo group. CONCLUSION: Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirement in laparoscopic cholecystectomy.