Postoperative acute pain management with duloxetine as compared to placebo: A systematic review with meta-analysis of randomized clinical trials.

BACKGROUND: Duloxetine has been used as an adjunct in multimodal analgesia for acute postoperative pain in clinical studies. This meta-analysis aims to conclude whether oral duloxetine, when given perioperatively, is any better than a placebo in managing postoperative pain. Effects of duloxetine on postoperative pain scores, time to first rescue analgesia, postoperative rescue analgesia consumption, side effects attributable to duloxetine, and patient satisfaction profile were assessed. METHOD: MEDLINE, Web of Science, EMBASE, Scholar Google, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched with keywords including "Duloxetine" AND "postoperative pain", "Duloxetine" AND "acute pain" and with "Duloxetine" till October 2022. This meta-analysis included randomized clinical trials in which perioperative duloxetine 60 mg per oral was administered not more than 7 days before surgery and for at least 24 after surgery but not more than 14 days after surgery. All RCTs in which the comparator is placebo and outcomes related to analgesic efficacy like pain scores, opioid consumption, and side effects of duloxetine until 48 h postoperatively were included. Data were extracted from the studies and a risk of bias summary was formed using the Cochrane Collaboration tool. Effect sizes were given as standardized mean differences for continuous outcomes and risk ratios (RR) by the Mantel-Haenszel test for the categorical outcome. Confirmation of publication bias was done by Egger's regression test (p < 0.05). If publication bias or heterogeneity was detected, the trim-and-fill method was used to calculate the adjusted effect size. Sensitivity analysis was done by leaving one out method after excluding the study with a high risk of bias. Subgroup analysis was done based on the type of surgery and gender. The study was prospectively registered in the PROSPERO under the registration number CRD42019139559. FINDINGS: 29 studies with 2043 patients met the inclusion criteria and were reviewed for this meta-analysis. Postoperative pain scores at 24 h [Std. Mean Difference (95% CI); -0.69 (-1.07, -0.32)] and at 48 h [-1.13 (-1.68, -0.58)] are significantly less with duloxetine (p-value < 0.05). Time to first rescue analgesia was significantly more in patients where duloxetine was administered [1.27 (1.10, 1.45); p-value > 0.05]. Opioid consumption up to 24 h [-1.82 (-2.46, -1.18)] and 48 h [-2.48 (-3.46, -1.50)] was significantly less (p-value < 0.05) in patients who received duloxetine. Complications and recovery profiles were similar in patients receiving either duloxetine or a placebo. INTERPRETATION: Based on GRADE findings, we conclude that there is low to moderate evidence to advocate the use of duloxetine for managing postoperative pain. Further trials are needed to replicate or refute these results based on robust methodology.

Combined femoral-obturator-sciatic nerve block has superior postoperative pain score and earlier ambulation as compared to spinal anaesthesia for arthroscopic anterior cruciate ligament reconstruction.

PURPOSE: Peripheral nerve blocks can be a suitable alternative to central neuraxial blockage, as the sole anaesthetic agent for better early postoperative outcomes, decreased hospital stay and earlier mobilisation after anterior cruciate ligament reconstruction (ACLR) surgery. The purpose of this study was to compare consciousness during the procedure, pain during early postoperative period (< 7 days), and perioperative outcomes following ACLR using combined sciatic, femoral, and obturator nerve blocks compared to the spinal anaesthesia. METHODS: This was a prospective case-control study including patients between 18 and 55 years of age, with anterior cruciate ligament (ACL) injury confirmed clinically and radiologically and undergoing ACLR. Patients were allocated in the two groups alternatively, group 1 included patients who received combined nerve blocks, and group 2 included patients who received spinal anaesthesia for the surgery. The sensory effect, motor effect, adequacy of anaesthesia, perioperative analgesic use, duration of stay, postoperative pain (visual analogue scale 0-10 cm) and functional outcomes were noted. RESULTS: There were 60 patients in each group. A total of seven patients in group 1 (11%) and two patients in group 2 (3%) needed conversion to general anaesthesia (n.s.). In group 1, out of 53 patients who underwent surgery, 26 patients had no perception of surgery in the joint, 17 patients had perception of manipulation of the knee joint, 4 patients had sense of touch, and 6 patients had sensation of pain in the knee (VAS scale less than 3). In group 2, out of 58 patients, 42 patients had no perception of surgery, 12 had a perception of manipulation of the knee joint, 2 had sense of touch, and 2 had sensation of pain in the knee. Blockage of sensory effect was significantly better in group 2 (p = 0.0001). However, the motor effect was comparable between the two groups (n.s.). Group 1 had significantly better pain scores 6, 12, and 18 h after the surgery. Moreover, patients in group 1 also had faster ambulation (mean difference of 5.5 h, p = 0.0001) and reduced hospital stay (mean difference of 8.4 h, p = 0.0001). CONCLUSION: Combined sciatic, femoral, and adductor canal block is an effective sole anaesthetic modality for ACLR. The sensory effect was inferior when compared to spinal anaesthesia but sufficient for the procedure without the need for supplementation with any other anaesthetic modality. Patients receiving this combined nerve block had lesser early postoperative pain scores, earlier ambulation, and shorter hospital stay as compared to the spinal anaesthesia. LEVEL OF EVIDENCE: Level 3.

Enhanced recovery protocol after single-stage bilateral primary total knee arthroplasty decreases duration of hospital stay without increasing complication rates.

PURPOSE: With an increasing number of total knee arthroplasty (TKA), protocols for better standard of patient care and shorter duration of hospital stay are necessary. Enhanced recovery (ER) protocols are becoming popular to meet these objectives. The current study aims to evaluate the clinical outcome of fast-track TKA using ER protocol in terms of length of hospital stay, perioperative complications and functional outcomes. METHODS: Patients undergoing single-stage bilateral primary TKA were prospectively included in the study. All patients went through a pre-defined ER protocol of TKA. Length of hospital stay, readmission rates, pain scores and functional scores of patients operated under ER protocol were compared with another matched historical control-group. Factors delaying the discharge of the patients by 48 h after the surgery were noted. RESULTS: We compared 275 patients undergoing single-stage bilateral primary TKA through ER protocol (Group 1) with 190 patients who had undergone bilateral primary TKA before the ER protocol was initiated (Group 2). The length of hospital stay (3.9 ± 2.1 days in group 1 and 7.5 ± 3.2 days in group 2, p 0.0001) and post-operative pain scores at 12 h (5.2 ± 2.9 in group 1 and 5.7 ± 2.1 in group 2, p 0.03) and 24 h (4.1 ± 1.6 in group 1 and 4.6 ± 1.4 in group 2, p 0.0005) were found to be significantly better with ER protocol. There was no difference in Oxford knee scores, infection rates, readmissions or mortality between the two groups. CONCLUSION: ER protocol in single-stage bilateral primary TKA resulted in decreased length of hospital stay without increasing complications and compromising the clinical outcome. It requires an integrated approach and adherence to clinical pathways. LEVEL OF EVIDENCE: Level II, Prospective comparative study.

Comparison of two different volumes of 0.5%, ropivacaine used in ultrasound-guided adductor canal block after knee arthroplasty: A randomized, blinded, controlled noninferiority trial.

Background and Aims: The aim of this study was to establish noninferiority of 10 mL of 0.5% ropivacaine as compared to 20 mL of 0.5% ropivacaine; for choosing right dose in adductor canal block (ACB) after knee arthroplasty (KA), this trial was conducted. Material and Methods: Forty patients undergoing bilateral KA with postoperative ultrasound-aided ACB were randomized: Group A patients received 20 mL 0.5% ropivacaine in the right limb and 10 mL 0.5% ropivacaine in the left limb. Group B patients received 10 mL of 0.5% ropivacaine in the right limb and 20 mL of 0.5% ropivacaine in the left limb. Catheter is positioned for intermittent boluses every 12-h up to 48 h. Results: In the final analysis (excluding six patients) based on split-body design between Group I (comprising 34 limbs which received 20 mL of 0.5% ropivacaine) and Group II (comprising 34 limbs which received 10 mL of 0.5% ropivacaine), baseline demographic data were collected. Length of the limb from anterior superior iliac spine (ASIS) to the base of the patella was comparable between two groups: Group I (in cm; 149 ± 1.63) versus Group II (in cm; 149.5 ± 1.51) (P = 0.49, 95% CI of - 1.98 to 0.98). Primary outcomes, that is, quadriceps muscle strength, show a significant difference (P < 0.025) at various timeline. Secondary outcome pain scores and degree of knee flexion at various time intervals showed no significant difference. There was zero incidence of fall of the patient and no significant complication due to catheter was reported leading to discontinuation of catheter use in both groups. Conclusion: 10 mL of 0.5% ropivacaine is noninferior to 20 mL of 0.5% ropivacaine in providing postoperative analgesia with preserved quadriceps muscle strength.

Comparative evaluation of analgesic efficacy of buprenorphine transdermal patch and fentanyl patch in management of postoperative pain after arthroscopic lower limb surgery: A randomized controlled trial.

BACKGROUND AND AIMS: Transdermal opioids are newer modality in use for the control of postoperative pain, because of its noninvasiveness, longer duration of action, sustained blood levels, and with minimal side effects. The study was aimed to evaluate the efficacy of analgesia of buprenorphine patch 10, 20 µg·h-1 and fentanyl patch 25 µg·h-1 for relief of pain in the postoperative period in patients undergoing arthroscopic lower limb surgeries. MATERIALS AND METHODS: It was a randomized, double-blinded, prospective study in which adult patients undergoing lower limb arthroscopic surgery were randomly segregated into three groups. In Group 1 (fentanyl patch 25 µg·h-1), Group 2 (buprenorphine patch 10 µg·h-1), and Group 3 (buprenorphine patch 20 µg·h-1), transdermal patches were applied 12 h prior to surgery. Mean NRS score, total rescue analgesic requirement, drug-related adverse effects, and hemodynamic status were evaluated till 72 h in the postoperative period. RESULTS: Out of 175 screened patients, 150 patients were finally analyzed. Baseline characteristics were the same among all the three groups. Median NRS score was lowest in Group 3 [P value < 0.05 at 2, 4, 8, 12, and 24 h after surgery (Kruskal Wallis test). The total consumption of postoperative rescue analgesic diclofenac was the lowest in Group 3 as compared to other groups without any significant increase in adverse events. CONCLUSIONS: In arthroscopic lower limb surgery, buprenorphine patch (20 µg·h-1) applied 12 h prior to surgery is an effective postoperative analgesic and it is not associated with any significant adverse effects.

Hindi translation and cultural adaptation of the quality of recovery score-40 (QoR-40 score): A validation study.

Background and Aims: The quality of recovery (QoR)-40 score has been used worldwide and validated in many surgical cohorts to assess global patient recovery. We aim to translate and culturally adapt the QoR-40 score into Hindi and test the validity and reliability of the translated version in patients undergoing cancer surgery. Methods: The translation of the QoR-40 questionnaire was based on the forward and backward translation methods. Patients filled out the translated version of the QoR-40 preoperatively, on the third postoperative day in the morning (POD3) and the evening. The reliability of the translated questionnaire was checked for internal consistency, test-retest reliability and split-half reliability. Construct validity was assessed with a correlation coefficient value between the total QoR-40 score, visual analogue scale (VAS) for pain and total length of hospital stay. Content validity was evaluated for feasibility and understanding. Results: The questionnaire was completed by 350 patients. The correlation coefficient r for repeatability was 0.21, the split-half test was 0.92, and Cronbach's alpha was 0.82. The correlation between QoR-40 on POD3 with VAS score and length of stay was -0.35 and -0.67, respectively. The average time to complete the questionnaire was 3.8 minutes; 90% of the respondents found the translated questionnaire easy to understand, and 92% of the patients related the questions to their recovery. Conclusion: The Hindi translation of the QoR-40 questionnaire is a valid and reliable version of the original questionnaire in English to assess the QoR in Hindi-speaking patients after cancer surgery.

A Randomized Double-Blind Study Evaluating Intraperitoneal Ropivacaine Nebulization With and Without Nalbuphine for Post-operative Analgesia in Laparoscopic Cholecystectomy.

OBJECTIVE: Local anaesthetics administered into the peritoneal cavity have been successfully used for post-operative pain relief in minimally invasive laparoscopic procedures. We intended to study and compare nebulized intraperitoneal ropivacaine with and without nalbuphine, with a placebo for post-operative pain relief in these surgeries. METHODS: A prospective, randomized double-blinded study was conducted over a period of 1 year after institutional ethical clearance, in patients undergoing elective laparoscopic cholecystectomy. Subjects were randomized into 3 groups (S: saline, R: ropivacaine, RN: ropiva- caine plus nalbuphine). The pain was assessed in the post-operative period using NRS scores (up to 24 hours). Kruskal-Wallis test was used for comparison, P < .05 was considered significant. Time to first rescue analgesia, total opioid requirement, and side effects were also recorded. RESULTS: Groups were similar in terms of demographic data. Patients in the placebo group reported higher NRS scores than the other 2 study groups till 4 hours post-operative (earlier rescue analgesia). The addition of nalbuphine did not cause any statistically significant improvement in post-operative pain relief (NRS) as compared to ropivacaine administered alone. Intraperitoneal ropivacaine nebulization had no significant adverse effect as compared to placebo. CONCLUSIONS: Ropivacaine nebulization with or without nalbuphine is more effective than placebo for post-operative pain relief after lapa- roscopic cholecystectomy without significant side effects. Addition of nalbuphine to ropivacaine nebulization does not significantly improve pain relief after laparoscopic cholecystectomy.

Effectiveness of four ultrasonographic parameters as predictors of difficult intubation in patients without anticipated difficult airway.

BACKGROUND: Predicting difficult intubation (DI) is a key challenge, as no single clinical predictor is sufficiently valid to predict the outcome. We evaluated the effectiveness of four upper airway ultrasonographic parameters in predicting DI. The validity of the models using combinations of ultrasonography-based parameters was also investigated. METHODS: This prospective, observational, double-blinded cohort trial enrolled 1,043 surgical patients classified as American Society of Anesthesiologists physical status I-III without anticipated difficult airway. Preoperatively, their tongue thickness (TT), invisibility of hyoid bone (VH), and anterior neck soft tissue thickness from the skin to thyrohyoid membrane (ST) and hyoid bone (SH) were measured by sublingual and submandibular ultrasonography. The logistic regression, Youden index, and receiver operator characteristic analysis results were reported. RESULTS: Overall, 58 (5.6%) patients were classified as DI. The TT, SH, ST, and VH had accuracies of 78.4%, 85.0%, 84.7%, and 84.9%, respectively. The optimal values of TT, SH, and ST for predicting DI were > 5.8 cm (sensitivity: 84.5%, specificity: 78.1%, AUC: 0.880), > 1.4 cm (sensitivity: 81%, specificity: 85.2%, AUC: 0.898) and > 2.4 cm (sensitivity: 75.9%, specificity: 85.2%, AUC: 0.885) respectively. VH had a sensitivity and specificity of 72.4% and 85.6% (AUC: 0.790). The AUC values of the five models (with combinations of three or four parameters) ranged from 0.975-0.992. ST and VH had a significant impact on the individual models. CONCLUSIONS: SH had the best accuracy. Individual parameters showed limited validity. The model including all four parameters offered the best diagnostic value.

Comparison of adductor canal block with femoral nerve block for post-operative pain relief after bilateral total knee arthroplasty: A non-randomised controlled trial.

BACKGROUND AND AIMS: Pain perception and pain threshold vary from one individual to another and also differ in the right and left limbs leading to an inter-cerebral pain variability bias and inter-patient pain variability bias. To date, data comparing adductor canal block (ACB) with femoral nerve block (FNB) in the same patient who underwent bilateral total knee arthroplasty (TKA) remain limited. METHODS: We performed a prospective, non-randomised, controlled study. Patients scheduled for bilateral TKA with central neuraxial anaesthesia received every 12-hourly intermittent boluses of 15 mL of ropivacaine 0.5% in two different peripheral nerve blocks (ACB and FNB) in either of the lower limbs postoperatively. The primary outcome was to assess postoperative VAS score, and the secondary outcomes were muscle strength of the quadriceps muscle and degree of flexion at the knee joint. RESULTS: Among the 80 patients assessed for eligibility, 72 patients were enroled, and 69 were included in the final analysis. VAS scores after the two blocks during rest at 30 minutes, 6 hours, 12 hours and 48 hours post-operatively had no significant difference. VAS scores during rest at 24 hours and on doing exercise at 24 hours and 48 hours showed a significant difference. Quadriceps muscle strength and degree of flexion of knee at 24 hours and 48 hours post-operatively did show a significant difference in favour of the ACB over FNB. CONCLUSION: ACB provides equivalent analgesia in comparison with FNB at rest and during passive exercise up to 48 hours post-operatively. ACB significantly preserved motor power of quadriceps muscles when compared with FNB with no added complications.

Effect of ultrasound-guided-pressure-controlled ventilation on intraoperative blood gas and ventilatory parameters during thoracic surgery.

BACKGROUND AND AIMS: Identifying an ideal intraoperative ventilation strategy remains an area of research. We evaluated the effect of ultrasound-guided-pressure-controlled ventilation (UG-PCV) on the blood-gas and ventilatory parameters, during both two-lung ventilation (TLV) and one-lung ventilation (OLV) for thoracic surgery of unilateral pulmonary disease, compared with volume-targeted PCV (VT-PCV). METHODS: In a prospective, parallel-group and double-blinded design, 40 consecutive patients were randomised into two groups. Group A: Received VT-PCV at a tidal volume (TV) of 9 mL/kg for TLV and 5 mL/kg for OLV; group B: Received UG-PCV at an inspiratory pressure (2 cmH2O increments every 15 s) targeted to achieve the alveolar aeration at the base of the dependent lung (ultrasound-guided), for both TLV/OLV, respectively. Primary outcome included arterial oxygen partial pressure (PaO2) measured at baseline before anaesthesia induction (T1), at 30 min immediately before conversion from TLV to OLV (T2), at 30 min on OLV (T3) and before terminating OLV at the end of surgery (T4). Statistical tool included Mann-Whitney test. RESULTS: The PaO2 (mmHg) was significantly higher in group B (374.5 ± 25.9, 321.7 ± 35.2 and 357.0 ± 24.7) as compared to group A (353.3 ± 38.1, 272.6 ± 37.9 and 295.3 ± 40.1), at T2, T3 and T4, respectively. The acid-base status remained preserved in group B, while gradual respiratory acidosis was observed in group A. The bicarbonate levels remained uniform in all patients. The TV and airway pressures were marginally higher in group B, with no intraoperative complications. CONCLUSION: The UG-PCV mode offered better oxygenation, homogenous acid-base balance and individualised alveolar ventilation for thoracic surgery.

Perioperative duloxetine as part of a multimodal analgesia regime reduces postoperative pain in lumbar canal stenosis surgery: a randomized, triple blind, and placebo-controlled trial.

BACKGROUND: Duloxetine is an antidepressant that is also useful in chronic neuropathic and central origin pain. In this study, the role of duloxetine in decreasing acute postoperative pain after lumbar canal stenosis surgery is explored. METHODS: In this single center, triple blinded, and placebo-controlled trial, 96 patients were randomized for statistical analysis. The intervention group received oral duloxetine 30 mg once a day (OD) for 2 days before surgery, 60 mg OD from the day of surgery to the postoperative second day and 30 mg OD for the next 2 days (a total duration of 7 days). A placebo capsule was given in the other group for a similar time and schedule. The same standard perioperative analgesia protocols were followed in both groups. RESULTS: Total morphine consumption up to 24 hours was significantly decreased in the duloxetine group (P < 0.01). The time to the first analgesia requirement was similar in both groups but the time to the second and third dose of rescue analgesia increased significantly in the duloxetine group. The time to ambulation was decreased significantly (P < 0.01) in the duloxetine group as compared to the placebo group. Pain scores remained similar during most of the time interval. No significant difference was observed in the complication rate and patient satisfaction score recorded. CONCLUSIONS: Duloxetine reduces postoperative pain after lumbar canal stenosis surgery with no increase in adverse effects.

Translation, cultural adaptation, and validation of the duke activity status index in the hindi language.

Background: The Duke Activity Status Index (DASI) is a validated questionnaire in English to assess the functional capacity (FC) of patients with cardiovascular disease (CVD). Aim: The aim of the study is to translate, cross-culturally adapt, and validate the DASI in Hindi. Settings and Study Design: Observational validation study. Methodology: Different translators translated the DASI into Hindi and then back-translated it into English. Validation for feasibility and psychometric properties of translated questionnaire was done on 200 adults, Hindi-speaking patients with CVD, who were advised exercise testing by a cardiologist. Statistical Analysis: Internal consistency (Cronbach's α) and test-retest reliability (Pearson's correlation coefficient) were calculated. Construct (correlation with the Canadian Cardiovascular Society Classification [CCSC] for angina and exercise capacity with treadmill testing [TMT]) and content validity (time taken to fill the questionnaire, ease of understanding the questionnaire items, and comprehensibility) were calculated.P < 0.05 was considered significant. Results: The Cronbach's α for internal consistency was 0.78, which indicates adequate relatedness among the items of questionnaire, and the test-retest reliability was 0.65 (P < 0.05). A significant correlation between CCSC (r = -0.60) and TMT (r = 0.56) was found. The median time taken by the respondents to fill the questionnaire was 4 min. Of all the respondents, 95.74% of the respondents agreed that the Hindi questionnaire was easy to comprehend and 97.87% patients correlated the translated items to their daily physical activity. Conclusions: The Hindi translated and culturally adapted version of the DASI is reliable, valid, and feasible to assess the FC in the Hindi-speaking CVD patients.

A randomized single-blinded, parallel-arm group feasibility trial evaluating role of pectoral nerve block on serum vascular endothelial growth factor levels in patients undergoing unilateral modified radical mastectomy.

Metastatic breast cancer cells carry adult and neonatal variants of NaV1.5 voltage-gated activated Na+ channels involved in cell invasion. We hypothesize that instilling lignocaine near the surgical field to anesthetize the pectoral nerves for analgesia will decrease angiogenesis by blocking voltage-gated activated Na+ channels. Twenty patients undergoing unilateral modified radical mastectomy were randomized in a single-blinded, parallel-arm group feasibility pilot study in two groups. In Group I a catheter was placed between the pectoralis major and minor muscle under direct vision before skin closure. Ten milliliters of 2% lignocaine was given as an initial bolus followed by 10 mL of 2% lignocaine every 8 hours up to 24 hours. Group II did not receive any regional block. Primary measure outcomes were pre and postoperative changes in levels of vascular endothelial growth factor. Secondary outcomes were postoperative pain scores and total rescue analgesia used. Nine patients in each group were analyzed. Baseline demographic data of all females were similar with respect to age, body mass, height and duration of anesthesia. Postoperative mean serum levels of vascular endothelial growth factor were decreased by 46.60% from baseline in Group I, while were increased by 84.27% as compared to preoperative values in Group II. Postoperative average pain scores were less in Group I. Postoperative rescue analgesia in 24 hours in Group I was lower than that in Group II. There was no postoperative adverse event related to catheter or lignocaine administration at given doses. Instilling lignocaine to block pectoral nerves provides better postoperative analgesia and decreases a marker of angiogenesis. The study protocol was approved by the Institutional Ethical Committee of the Tertiary Centre (All India Institute of Medical Sciences Rishikesh India) (No. AIIMS/IEC/19/1002) on August 9, 2019, and the larger expansion trial was prospectively registered on Clinical Trial Registry India (No. CTRI/2020/01/022784) on January 15, 2020.

Comparison of Subcostal Transversus Abdominis Block with Intraperitoneal Instillation of Levobupivacaine for Pain Relief after Laparoscopic Cholecystectomy: A Prospective Study.

BACKGROUND: There are several methods employed in the management of postoperative pain after laparoscopic cholecystectomy such as conventional systemic analgesics, including paracetamol, non-steroidal anti-inflammatory drugs, systemic opioids, and thoracic epidural analgesia with all having its limitations and side effects. AIMS: The present study aims to compare ultrasound-guided subcostal transversus abdominis (STA) block with intraperitoneal instillation of levobupivacaine in reducing postoperative pain, total analgesic consumption, nausea and vomiting, and recovery time in patients after elective laparoscopic cholecystectomy. SETTINGS AND DESIGN: A prospective study was conducted between January 2017 and December 2017 in 80 patients undergoing elective laparoscopic cholecystectomy after approval of the Institutional Ethical Committee (Reference No: SGRR/IEC/05/16). MATERIALS AND METHODS: Patients were randomly divided into two equal-sized (n = 40) study groups. Group 1 patients received ultrasonography-guided STA block with 0.25% levobupivacaine both sides and Group 2 patients received 0.25% levobupivacaine through intraperitoneal route. STATISTICAL ANALYSIS: Quantitative data were expressed in mean and standard deviation. Qualitative data were expressed in proportion and percentages. Independent t-test was applied to compare the means of quantitative data and the Chi-square test was used to compare categorical data. P < 0.05 was considered to be statistically significant. Survival curve was drawn using the log-rank test for comparing two groups. RESULTS: Patient characteristics regarding age, gender, and weight were comparable in the two groups. The mean Numerical Rating Scale scores were less in Group 1 than in Group 2 in the first 6 h, which was found to be statistically significant. There was no significant difference noted in pain scores after 6 h up to 24 h in postoperative area among the two groups. Pain scores for shoulder tip pain were lower in Group 2 as compared to Group 1 in the first 24 h, which was not significant statistically. CONCLUSION: STA block is a better modality for analgesia compared to intraperitoneal instillation in patients undergoing elective laparoscopic cholecystectomy.

Intraoperative Comparison and Evaluation of Intrathecal Bupivacaine Combined with Clonidine versus Fentanyl in Children Undergoing Hernia Repair or Genital Surgery: A Prospective, Randomized Controlled Trial.

BACKGROUND: Nowadays, spinal anesthesia is commonly being used in infants and children for infraumblical surgeries. Intrathecal adjuvants such as clonidine and fentanyl are used with local anesthetics for additive effects. AIM: The present study aims to assess and compare the effects of adding clonidine versus fentanyl to bupivacaine intrathecally in terms of propofol consumption, hemodynamic profile, adverse events, and complications intraoperatively in pediatric patients. SETTINGS AND DESIGN: A prospective randomized controlled trial was conducted between June 2016 and October 2018 in pediatric patients aged 3-8 years undergoing hernia repair or genital surgery under spinal anesthesia after approval of the Institutional Ethical Committee (Reference No: SGRR/IEC/04/16). MATERIALS AND METHODS: Patients were randomly divided into two equal sized (n = 42) study groups, while analysis was done in (n = 40) each group. Group 1 (BC) received clonidine 1 µg/kg with 0.5% bupivacaine (heavy) and Group 2 (BF) received fentanyl 0.5 µg/kg with 0.5% bupivacaine (heavy). STATISTICAL ANALYSIS: Quantitative data were expressed in mean and standard deviation. Qualitative data were expressed in proportion and percentages. Independent t-test was applied to compare the means of quantitative data, and Chi-square test was used to compare categorical data. P < 0.05 was considered statistically significant. RESULTS: Patient characteristics regarding age, weight, and surgical time were comparable in the two groups. The maintenance dose and bolus dose of propofol consumed during surgery were less in Group 1 than that in the Group 2 and were found to be statistically insignificant. The values of hemodynamic parameters such as heart rate, systolic blood pressure, and diastolic blood pressure were less in Group 1 and were statistically significant at different time intervals. Sedation scores were comparable in both groups. Intraoperative incidence of bradycardia, systolic hypotension, and diastolic hypotension were high in Group 1, whereas the incidence of desaturation was high in Group 2. Intraoperative complications such as apnea and respiratory obstruction were high in Group 2, but were statistically insignificant. CONCLUSION: We conclude that intrathecal adjuvant fentanyl maintains a better hemodynamic profile in terms of adverse events such as bradycardia, systolic hypotension, and diastolic hypotension. Intrathecal clonidine maintains a better sedation level requiring less propofol for sedation. Complications such as apnea and respiratory obstruction can be attributed more to the deep sedation caused by bolus of propofol rather than the inherent properties of intrathecal adjuvant clonidine or fentanyl.

Giant Occipitocervical Encephalocele.

Encephaloceles are cranial defects in which sac contains herniating brain, which is often gliotic. Congenitally, this defect may extend into posterior elements of cervical vertebrae and leads to occipitocervical encephalocele. When the size of this sac is larger than head size, they are termed as giant. Very young age and associated congenital anomalies in these patients pose significant challenges in diagnostic, anesthetic, and surgical techniques. We share a case of giant occipitocervical encephalocele managed at our institute and discuss about its management issues with review of literature.

Intraperitoneal Levobupivacaine with or without Clonidine for Pain Relief after Laparoscopic Cholecystectomy: A Randomized, Double-blind, Placebo-controlled Trial.

BACKGROUND: Irrigation of local anesthetic intraperitoneally in combination with opioids and non-opioids agents has been used to provide pain relief with varying success in laparoscopic surgeries. This randomized double blind placebo controlled study is designed to study the effect of intraperitoneal instillation of levo-bupivacaine along with clonidine for pain relief after laparascopic cholecystectomy. METHODS: 75 patients were randomized to receive 20 ml of 0.9% normal saline as placebo (group I), 20 ml of 0.5% levo bupivacaine (group II) and 20 ml of 0.5% levo bupivacaine with 1mcg/kg clonidine (group III) intraperitoneally. The degree of postoperative pain was assessed using the VAS and VRS on the immediate arrival in the recovery room after surgery and thereafter at 2, 4, 8, 12 and 24 hours, postoperatively. Statistical analysis was performed with ANOVA, the Kruskal-Wallis test followed by the Wilcoxon matched pairs rank test was used and P < 0.05 were considered significant. RESULTS: VAS was maximum in placebo (group I) than in levobupivacaine alone (group II) and was minimum in levobupivacaine with clonidine (group III) at all time intervals. The difference between group I and II is statistically significant at immediate and at 2 hours postoperatively but no difference were found between group I and II after 2 hour. However, there is statistically significant difference (P < 0.05) between group I and III and group II and III at all time intervals. CONCLUSION: Intraperitoneal instillation of levobupivacaine along with clonidine in a dose of 1mcg/kg is superior to levobupivacaine alone without having any significant adverse effects.