Comparison of the analgesic efficacy of two different fascial blocks in patients undergoing laparoscopic inguinal hernia surgery: A randomized control trial.

Background and Aims: Moderate-to-severe intensity pain is reported on the first day following lower abdominal surgery. No study has compared transversus abdominis plane (TAP) block with retrolaminar block (RLB) in laparoscopic inguinal hernia surgery for postoperative pain relief. Material and Methods: In this prospective, randomized trial, 42 male patients of American Society of Anesthesiologists (ASA) physical status I and II, aged 18-65 years, and having a BMI <40 kg/m2 received TAP or RLB following laparoscopic inguinal hernia surgery. A standard general anesthetic technique was performed. Patients were randomized into two groups: single-shot TAP block (group I) (n = 21) or the RLB (group II) (n = 21) with bilateral 20 ml of 0.375% ropivacaine. Postoperatively, IV paracetamol 1 g was administered as rescue analgesia. Postoperative cumulative Visual Analogue Scale (VAS) score 24 hours after surgery was considered as the primary outcome. Results: Postoperative cumulative VAS score at rest at 24 h, represented as mean ± S.D (95% CI), in the TAP block group was 3.54 ± 3.04 (2.16-4.93) and in the RLB group was 6.09 ± 4.83 (3.89-8.29). P value was 0.112 and VAS on movement was 7.95 ± 3.41 (6.39-9.50 [2.5-15.0]) in TAP block group, whereas P value was 0.110 and VAS on movement was 10.83 ± 5.51 (8.32-13.34) in the RLB group. Conclusion: Similar postoperative cumulative pain score on movement at 24 h was present in patients receiving TAP block or RLB. However, VAS score at rest and on movement was reduced in patients receiving TAP block at 18 and 24 h postoperatively.

Analgesic efficacy of programmed intermittent epidural bolus vs patient-controlled epidural analgesia in laboring parturients.

Background and Aims: Programmed intermittent epidural boluses (PIEB) may produce more extensive spread of epidural bolus rather than continuous epidural infusion (CEI). Previous studies compared PIEB with CEI and concluded that PIEB shows better outcome when combined with patient controlled epidural analgesia (PCEA), but these studies lack any comparison between PCEA and PIEB in the absence of CEI. Material and Methods: In this open labeled, prospective, randomized, controlled study 50 parturient were randomly assigned to two groups of 25 each. Group 1 received PCEA bolus of 5 ml (0.1% levobupivacaine plus 2mcg/ml fentanyl) with 15 min lockout interval with provision of rescue clinician bolus of 5 ml of same drug for breakthrough pain. Group 2 received physician-administered PIEB with same parameters as Group 1. The primary outcome was to assess total consumption of levobupivacaine plus fentanyl mixture, in PIEB vs. PCEA group, corrected for duration of labor (ml/h) and secondary outcomes included pain score, maternal satisfaction, maternal, and neonatal characteristics. Results: The hourly mean drug consumption in the PCEA group was significantly lower as compared with the physician-administered PIEB group (5.46 ml/h, SD 2.01 vs. 6.55 ml/h, SD 1.28; P = 0.03). The median total number of rescue boluses consumed were less in the PCEA group when compared with the PIEB group (0 vs. 1; P < 0.001). There was no significant difference between groups with regard to pain scores, maternal hemodynamics, maternal and fetal outcome and adverse effects. Conclusion: PCEA may be better than physician-administered PIEB in providing effective labor analgesia with comparable safety.

Topical vs. intravenous administration of tranexamic acid to minimize blood loss in abdominal hysterectomy perioperatively: A randomized controlled study.

Background and Aims: Topical application of tranexamic acid (TXA) to bleeding wound surfaces is rapidly gaining recognition and currently a topic of further research in patients undergoing abdominal hysterectomy. The aim of the study was to compare the efficacy of topical vs. intravenous (i.v.) administration of TXA in reducing perioperative blood loss in patients undergoing abdominal hysterectomy. Material and Methods: A double-blinded parallel-group randomized controlled study was conducted in a tertiary teaching institute. Group 1 (n = 25) received 10 mg.kg-1 i.v. bolus of TXA after induction followed by infusion of 1 mg.kg-1.h-1 of TXA, in 50 ml of normal saline (NS), till the completion of surgery and just before closure of peritoneum 100 ml of NS was applied topically over the raw surface. Group 2 (n = 25) received 50 ml of NS over 10 min after induction, followed by infusion of 50 ml of NS, till the completion of surgery and just before closure of peritoneum, 1.5 g of TXA mixed in 100 ml of NS was applied topically over the raw surface. The primary outcome was total perioperative blood loss (intraoperative plus 24 h postoperative). The secondary outcomes included change in hemoglobin concentration postoperatively at 12 h, 24 h; need for blood/blood product transfusion; amount of blood/blood product transfused and side effects of TXA. Results: Total perioperative blood loss was 312 ± 106.65 ml in group 1 and 325 ± 89.90 ml in group 2 (p = 0.659). It was found that the mean reduction in hemoglobin was 0.7 g.dl-1 and 0.54 g.dl-1 in group 1 and 0.67 g.dl-1 and 0.44 g.dl-1 in group 2 at 12 h and 24 h respectively, with no significant intergroup difference. Conclusion: Administration of TXA topically is as efficacious as TXA administered i.v. to minimize perioperative blood loss in patients undergoing abdominal hysterectomy.

Oral acetaminophen as an adjunct to continuous epidural infusion and patient-controlled epidural analgesia in laboring parturients: a randomized controlled trial.

BACKGROUND: Intravenous acetaminophen is safe and effective as an adjunct to labor analgesia with combined spinal-epidural (CSE) analgesia and patient-controlled epidural analgesia (PCEA). Oral acetaminophen is a much cheaper and safe option but has not been studied as an adjunct to labor analgesia till date. The aim of the present study is to evaluate the effect of oral acetaminophen as an adjunct in patients receiving local anesthetic-opioid combination using CSE analgesia. METHOD: In this ethically approved randomized double-blind placebo-controlled trial, 60 consenting parturients were randomly allocated to two groups of 30 each: acetaminophen (who received oral acetaminophen 1 g) or placebo, 45 min before the procedure. CSE was administered as per hospital protocol. All the patients received continuous epidural infusion (CEI) of levobupivacaine 0.1% and fentanyl 2 mcg/mL at 5 ml/h and PCEA boluses of 5 mL of the same drug with a lockout interval of 15 min if needed. The primary outcome was hourly mean consumption of levobupivacaine and fentanyl mixture (mL/h). Secondary outcomes included pain score, sensory and motor block, hemodynamic parameters of mother, duration of the second stage of labor, mode of delivery, maternal satisfaction, Apgar scores, fetal heart rate, and adverse effects. RESULTS: The mean drug consumption per hour was significantly less in the acetaminophen group than in the placebo group (7.66 mL/h, SD 2.01 vs. 9.01 mL/h, SD 2.83; p = 0.04). The requirement for bolus was also significantly less in the acetaminophen group than in the placebo group (median 2.5, IQR 3 vs. median 3.5, IQR 2; p = 0.04). CONCLUSION: The use of 1 g of oral acetaminophen could be a cheap, safe, and effective adjunct to CEI plus PCEA in labor analgesia.

Clinical Utility of the Behavioral Pain Assessment Tool in Patients Admitted in the Intensive Care Unit.

INTRODUCTION: Unnoticed and unrelieved pain is one of the main sources of psychological and physiological stress for intensive care unit (ICU) patients. The eight-item behavior pain assessment tool (BPAT) is a multicountry validated tool to assess pain in ICU patients. However, its feasibility and clinical utility for ICU patients in India need further research. AIMS AND OBJECTIVES: The Aims and objectives of the study were to assess pain using BPAT and its clinical utility in pain assessment and management in ICU patients. MATERIALS AND METHODS: Following ethical approval, 400 consecutive adult patients admitted in the ICUs in a tertiary care teaching hospital were assessed for pain severity using BPAT at intake, baseline pain and procedural pain. Patients <18 years and in deep coma on the Glasgow coma scale were excluded from the study. The patients with BPAT score ≥4 were given opioid analgesic, and their pain was reassessed after 2-3 hours. A feedback regarding feasibility and clinical utility was filled by the doctors. RESULTS: High interrater agreement for BPAT was observed with excellent kappa coefficients (>0.85) for each item. The BPAT significantly guided the pain management (p < 0.0001). More than 90% of doctors found BPAT easy to understand and use. In most of the cases (95.5%), doctors agreed that BPAT can improve the clinical management of ICU patients. CONCLUSION: The BPAT is a reliable, brief, and an easy-to-use pain assessment tool, which clinicians can use for guiding pain assessment and management in the ICU setting on a routine basis. CLINICAL SIGNIFICANCE: We recommend implementing BPAT in the clinical practice for better pain assessment and control in ICU patients. HOW TO CITE THIS ARTICLE: Mitra S, Jain K, Singh J, Saxena P, Nyima T, Selvam SR, et al. Clinical Utility of the Behavioral Pain Assessment Tool in Patients Admitted in the Intensive Care Unit. Indian J Crit Care Med 2020;24(8):695-700.

Anesthesiologist and COVID-19-current perspective.

In the current situation when the world is grappling with COVID-19 that has taken a toll on humanity and is continuing to affect multiples of health-care workers all over the world in vast numbers, the pandemonium (mayhem) has led to grim concerns. We have made an effort to compile and present a review that provides an insight into the management of patients for the front-line anesthesiologists of the medical war, which is being fought to curb and contain this COVID-19 pandemic. We have tried to incorporate the operating room locations, as well as the remote locations where anesthesiologist may be called upon for providing their services. Needless to say, it is of utmost importance to ensure the safety of the patient, as well as of the anesthesiologist who are involved in the patient care at this crucial juncture. The present article provides valuable information to anesthesiologists regarding handling the current pandemic in a protocolized and evidence-based manner.

Protocolized approach to a COVID-19 parturient undergoing a cesarean section - A case report.

The health care workers working in the operation theater (OT) face many unique challenges to deal with the corona virus disease (COVID-19) patients undergoing surgery. We hereby report the management of a COVID-19 parturient undergoing cesarean section in the dedicated COVID health center. Patient care of this special and vulnerable subset of population with least exposure of COVID-19 to health care worker was the cornerstone of the management. We have summarized some of the important precautionary measures which were taken during cesarean section to minimize exposure and genuine use of resources in this pandemic. To conclude, despite Personal Protective Equipment (PPE), precautionary measures and strategies are of utmost importance and should be opted so as to lower the virus contagion risk.

Does an acute pain service improve the perception of postoperative pain management in patients undergoing lower limb surgery? A prospective controlled non-randomized study.

BACKGROUND AND AIM: An acute pain service (APS) has been running in our institute since April 2013 and is managed by the Department of Anesthesia and Intensive Care. However, it is not clear to what extent the patients feel benefited from the APS. The aim of the study was to compare the perception of postoperative pain management in patients receiving care under APS with those receiving routine postoperative pain relief following lower limb surgery. MATERIAL AND METHODS: This was a prospective, hospital-based, controlled non-randomized study. American Society of Anesthesiologists (ASA) grades I-III patients with age 18-75 years undergoing lower limb orthopedic surgery were prospectively recruited into APS (index group) or routine postoperative care (control group) (n = 55 each). Postoperatively, American Pain Society Patient Outcome Questionnaire-Revised (APS-POQ-R) and Short Form (SF-12) were used to evaluate the outcome of postoperative pain management at 24 h and health-related quality of life after 4 weeks respectively. RESULTS: Both groups were comparable in terms of demographic data. Patients in the index group had statistically significant better perception of care than the control group. Index group scored significantly higher than control group on median patient satisfaction score (9; interquartile range [IQR] [7-10] vs. 5 [3-6]; P < 0.001). In index group, there was significant reduction of worst pain in first 24 h along with decreased frequency of severe pain. CONCLUSION: Implementation of acute pain service plays an important role in improving the quality of postoperative pain relief, perception of care, and patient satisfaction.

New Advances in Acute Postoperative Pain Management.

PURPOSE OF REVIEW: Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management. RECENT FINDINGS: Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations. In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.

Effect of Age of Transfused Red Blood Cell Units on Clinical Outcomes in Critically Ill Patients.

Anemia in critically ill patients requires red cell transfusions to increase oxygen delivery and prevent deleterious outcomes. The primary objective of the present study was to determine the effect of storage age of transfused red cells on 30-day mortality in critically ill patients, with secondary objectives of determining the effect on length of stay, organ failure, and adverse transfusion reactions. This prospective study was conducted on patients admitted to the intensive care unit after obtaining approval from institutional ethics committee. Patients were randomized to transfusion with packed red blood cells (PRBC) with age of collection either ≤ 14 days (Group 1) or > 14 days (Group 2). APACHE II scores were calculated at admission. Patients were followed up for primary outcome of 30-day mortality, and secondary outcomes including length of stay, infections, organ dysfunction, and adverse transfusion reactions. The 30-day mortality was 20% in Group 1 and 28% in Group 2 (p = 0.508). The mean storage duration of PRBC in Group 1 versus Group 2 was 8.48 days versus 21.43 days (p < 0.001). There was no significant difference in total number of PRBC transfusions, donor exposures, hemoglobin and hematocrit increment, adverse transfusion reactions, length of stay and organ dysfunction scores between the two groups. Transfusion of packed red cells of less than 14 days showed no benefit over red cells stored more than 14 days in terms of 30-day mortality, length of stay and infections in critically ill patients, however studies with larger sample size and longer follow up are recommended.

Post-GWAS functional analyses of CNTNAP5 suggests its role in glaucomatous neurodegeneration.

Primary angle closure glaucoma (PACG) affects more than 20 million people worldwide, with an increased prevalence in south-east Asia. In a prior haplotype-based GWAS, we identified a novel CNTNAP5 genic region, significantly associated with PACG. In the current study, we have extended our perception of CNTNAP5 involvement in glaucomatous neurodegeneration in a zebrafish model, through investigating phenotypic consequences pertinent to retinal degeneration upon knockdown of cntnap5 by translation-blocking morpholinos. While cntnap5 knockdown was successfully validated using an antibody, immunofluorescence followed by western blot analyses in cntnap5-morphant (MO) zebrafish revealed increased expression of acetylated tubulin indicative of perturbed cytoarchitecture of retinal layers. Moreover, significant loss of Nissl substance is observed in the neuro-retinal layers of cntnap5-MO zebrafish eye, indicating neurodegeneration. Additionally, in spontaneous movement behavioural analysis, cntnap5-MO zebrafish have a significantly lower average distance traversed in light phase compared to mismatch-controls, whereas no significant difference was observed in the dark phase, corroborating with vision loss in the cntnap5-MO zebrafish. This study provides the first direct functional evidence of a putative role of CNTNAP5 in visual neurodegeneration.

Real-time ultrasound guided percutaneous dilatational tracheostomy in critically ill patients: A step towards safety!

There are few reports and observational data that support the safety and efficacy of real-time ultrasound guided (USG) percutaneous dilatational tracheostomy (PDT) when compared with unguided tracheostomy. We performed real-time USG PDT in our intensive care unit (ICU) patients with the aim of providing safe and cost effective point-of-care management. Real-time ultrasonography has the potential advantage of enabling the clinicians to define the needle path by showing displacement of tissues ahead of needle.

Successful Management of Unilateral Post-traumatic Neuropathic Mastalgia: A Case Report.

Stellate ganglion block has been described in the management of postmastectomy neuropathic pain. However, its role in the treatment of posttraumatic neuropathic breast pain has not been reported in the literature. We present a case of a 40-year-old female with a chief complaint of severe debilitating pain in her right breast following trauma, refractory to oral medications including conventional analgesics, amitriptyline, pregabalin, and duloxetine. She was successfully managed after administration of ultrasound-guided stellate ganglion block and pulsed radiofrequency ablation of the stellate ganglion. It resulted in significant and prolonged pain relief leading to improved quality of life.

Neuroimaging Findings in Vitamin B12-Deficient Infants With Neurologic Features.

Background:Vitamin B12 deficiency causes serious neurologic problems among infants. However, its neuroradiologic correlate is still largely obscure. Methodology: This prospective study was conducted on patients aged 6 months to 2 years. All children with proven vitamin B12 deficiency were planned to undergo magnetic resonance imaging (MRI) and magnetic resonance spectroscopy of the brain. Results: A total of 35 patients (63% female) were enrolled. Twenty-six (74%) patients had significant findings on brain MRI scan, commonest of which were thinning of corpus callosum and prominence of extra-axial spaces in 28.6% children, cerebral atrophy in 17%, and diffuse symmetrical hyperintensity of white matter in 5.7% patients. Using logistic regression, it was found that odds of abnormal neuroimaging findings were higher in children below 12 months, in females, and in patients with developmental regression, but none of them were statistically significant. Conclusion: Most of the infants with vitamin B12 deficiency have abnormal neuroimaging findings.

A Randomized Controlled Trial Comparing the Analgesic Efficacy of Programmed Intermittent Bolus vs. Continuous Infusion of Ropivacaine and Fentanyl in Ultrasound-Guided Infraclavicular Brachial Plexus Block for Upper Limb Surgery.

BACKGROUND: Programmed intermittent bolus (PIB) is a novel method of intermittent drug delivery commonly employed in labor epidural analgesia. This study aimed to evaluate the potential benefits of PIB over continuous infusion (CI) for postoperative analgesia following upper limb surgeries distal to the mid-humerus level using ultrasound-guided infraclavicular brachial plexus block (USG-IBPB). METHODS: The USG-IBPB was performed on a total of 30 patients scheduled for upper limb surgery distal to the mid-humerus level. The patient-controlled regional analgesia pump delivered a combination of 6 mL of 0.2% ropivacaine and 2 µg/mL fentanyl via a perineural catheter as PIB in group I and as a CI in group II. The primary outcome measure was overall drug consumption, and secondary outcomes included pain scores, patient satisfaction, sensory and motor blockade, and adverse effects. RESULTS: The PIB group exhibited significantly lower overall drug consumption (306.20 ± 13.07 mL vs. 323.73 ± 11.79 mL; P = 0.001), a reduced need for patient-controlled analgesia boluses (3.87 ± 2.67 vs. 7.13 ± 2.36; P = 0.001), and higher patient satisfaction (91.93 ± 10.09 vs. 78.67 ± 17.57; P = 0.017) compared to the CI group. Pain scores at rest were significantly lower at the 24-hour mark (P = 0.007), and on movement, lower scores were observed after 1, 24, and 36 hours (P = 0.031, P = 0.031, and P = 0.011, respectively). Sensory block, motor block, and adverse effects were similar between the two groups. CONCLUSION: PIB demonstrated superior efficacy in postoperative analgesia compared to the CI technique for upper limb surgeries distal to the mid-humerus level. Therefore, PIB may be considered an effective alternative to CI for optimal postoperative pain management.

Erector spinae plane block for post-operative analgesia in thoracolumbar spine surgery: A randomised controlled trial.

Background and Aims: Thoracolumbar spine surgery is one of the most painful surgical procedures. This study's primary objective was to evaluate the effect of erector spinae plane (ESP) block on post-operative cumulative morphine consumption at 24 h in patients undergoing thoracolumbar spine surgery. Methods: Seventy adults posted for thoracolumbar spine surgery were randomised into the control group [Number of patients (n)=35], who received general anaesthesia without any nerve block, and the intervention group (n = 35), who received bilateral ultrasound (US)-guided ESP block at the level of spine surgery with 0.25% bupivacaine 20 mL after standard general anaesthesia. Along with intravenous patient-controlled analgesia morphine, post-operative analgesia was standardised for both groups. Total morphine consumption, visual analogue scale (VAS) score to evaluate pain, overall patient satisfaction, and any side effects were compared at 24 h. The statistical analysis was done using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL). Results: Post-operative total morphine consumption at 24 h was significantly decreased in the intervention group compared to the control group [5.69 (1.549) versus 9.51 (1.634) mg; P < 0.001]. Post-operative VAS scores were also significantly decreased in the intervention group at rest (P < 0.001) and on movement (P < 0.001). Patient satisfaction scores were more favourable in the intervention group [3.8 (0.4) versus 3.2 (0.6); P < 0.001]. Post-operative nausea and vomiting were found more in the control group but were not significant (n = 14 versus 8; P = 0.127). Conclusion: US-guided ESP block significantly reduces post-operative morphine consumption and improves analgesia and patient satisfaction without adverse effects in patients undergoing thoracolumbar spine surgery.

Acute pain in undergraduate medical education: an unfinished chapter!

Inadequately treated acute pain is a global healthcare problem that causes significant patient suffering and disability, risk of chronicity, increased resource utilization, and escalating healthcare costs. Compounding the problem is the lack of adequate instruction in acute pain management available in medical schools worldwide. Incorporating acute pain diagnosis and management as an integral part of the medical school curriculum will allow physicians to develop a more comprehensive, compassionate approach to treating patients with acute pain syndromes and should be considered a healthcare imperative. In this article, we review the current status of pain education in educational institutions across the world, focusing on achievements, lacunae, and inadequacies. We appeal to all concerned--pain management specialists, health educators, and policymakers--to consider incorporating education on acute pain and its management at undergraduate medical levels in an integrated manner.

Pain relief in laparoscopic cholecystectomy--a review of the current options.

Pain relief after laparoscopic cholecystectomy (LC) is an issue of great practical importance. Pain after LC has several origins: incisional, local visceral, peritoneal, and referred. Several modalities have been employed for achieving effective and safe analgesia: nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors, gabapentinoids, local anesthetics, and transversus abdominis plane (TAP) block. They have their advantages and disadvantages, and multimodal approaches are often followed because of the multiple sources of pain. Among COX-2 inhibitors, parecoxib and valdecoxib are useful, and fears regarding their cardiovascular adverse effects in noncardiac surgery (such as LC) have not been substantiated when used in short term. Gabapentin is useful but more data are needed regarding pregabalin because of inconsistent results. Local anesthetics (LA) can be particularly useful, both port-site infiltration and intraperitoneal instillation in the intra-operative period. Factors enhancing the effectiveness of these agents include early instillation before creating the pneumoperitoneum, larger volume of medium used for instillation, and favorable pharmacological characteristics of the agent. Combination of LA with either NSAID/COX-2 inhibitors or fibrin sealant appears to be effective, although more research is required for determining the exact combinations and efficacy using direct comparisons with single-modality interventions. Finally, newer procedures such as TAP block appear promising if replicated.