Comparative study to assess the quality of analgesia of bupivacaine and bupivacaine with dexmedetomidine in ultrasound-guided pectoral nerve block type I and II in breast surgeries.

BACKGROUND AND AIMS: Dexmedetomidine has been demonstrated to be safe and efficacious in prolonging the duration of peripheral nerve blocks. This study was designed to compare the duration, quality of postoperative analgesia, hemodynamic stability, and patient's satisfaction with addition of dexmedetomidine to bupivacaine versus plain bupivacaine in pectoral nerve block (Pecs) type I and II in breast surgeries. MATERIAL AND METHODS: This prospective randomized double-blind study was carried out in 60 American Society of Anesthesiologists grade I-III female patients, aged 18-70 years randomly allocated into two equal groups. Group A received 10 ml 0.25% bupivacaine for pecs I block and 20 ml 0.25% bupivacaine for pecs II block. Group B received 10 ml 0.25% bupivacaine with dexmedetomidine for pecs I block and 20 ml 0.25% bupivacaine with dexmedetomidine in pecs II block, keeping a total dose of dexmedetomidine of 1 µg/kg body weight and the volume constant in both the groups. RESULTS: Numerical rating scores at rest and on abduction of arm were significantly lower in Group B. There was a 40% increase in duration of complete analgesia in dexmedetomidine group (1024.0 ± 124.9 min) compared to plain bupivacaine (726.4 ± 155.3 min; P < 0.001). Total consumption of injection diclofenac sodium in 24 h was 23% less in Group B (77.5 ± 13.6 mg) compared to Group A (100.0 ± 35.9 mg, P = 0.003). Patient satisfaction score was significantly better in dexmedetomidine group. No adverse effects were noted in either group. CONCLUSION: Dexmedetomidine as an adjunct to bupivacaine helps prolong the duration and improves the quality of postoperative analgesia in pecs I and II block without serious side effects.

To evaluate the analgesic effectiveness of bilateral erector spinae plane block versus thoracic epidural analgesia in open cardiac surgeries approached through midline sternotomy.

BACKGROUND: The efficacy of the erector spinae plane (ESP) block in mitigating postoperative pain has been shown for a range of thoracic and abdominal procedures. However, there is a paucity of literature investigating its impact on postoperative analgesia as well as its influence on weaning and subsequent recovery in comparison to thoracic epidural analgesia (TEA) in median sternotomy-based approach for open-cardiac surgeries and hence the study. METHODS: Irrespective of gender or age, 74 adult patients scheduled to undergo open cardiac surgery were enrolled and randomly allocated into two groups: the Group TEA (thoracic epidural block) and the Group ESP (bilateral Erector Spinae Plane block). The following variables were analysed prospectively and compared among the groups with regard to pain control, as determined by the VAS Scale both at rest (VASR) and during spirometry (VASS), time to extubation, quantity and frequency of rescue analgesia delivered, day of first ambulation, length of stay in the intensive care unit (ICU), and any adverse cardiac events (ACE), respiratory events (ARE), or other events, if pertinent. RESULTS: Clinical and demographic variables were similar in both groups. Both groups had overall good pain control, as determined by the VAS scale both at rest (VASR) and with spirometry (VASS) with Group ESP demonstrating superior pain regulation compared to Group TEA during the post-extubation period at 6, 9, and 12 h, respectively (P > 0.05). Although statistically insignificant, the postoperative mean rescue analgesic doses utilised in both groups were comparable, but there was a higher frequency requirement in Group TEA. The hemodynamic and respiratory profiles were comparable, except for a few arrhythmias in Group TEA. With comparable results, early recovery, fast-track extubation, and intensive care unit (ICU) stay were achieved. CONCLUSIONS: The ESP block has been found to have optimal analgesic effects during open cardiac surgery, resulting in a decreased need for additional analgesic doses and eliminating the possibility of a coagulation emergency. Consequently, it presents itself as a safer alternative to the potentially invasive thoracic epidural analgesia (TEA).

A Comparative Study of Ultrasound-Guided Continuous Adductor Canal Block With Ultrasound-Guided Continuous Femoral Nerve Block in Unilateral Total Knee Arthroplasty for Limb Mobilization and Analgesic Efficacy.

Background Total knee joint replacement surgery is associated with severe postoperative pain and is amenable to regional anesthesia techniques for pain control. Femoral nerve block (FNB) provides effective analgesia after total knee arthroplasty (TKA) but has been associated with delayed ambulation due to quadriceps muscle weakness. Adductor canal block (ACB) may be a promising alternative, with less effect on the quadriceps muscle and comparable analgesic efficacy. We evaluated the effectiveness, safety, and patient satisfaction of continuous ACB augmented with infiltration between the popliteal artery and capsule of the knee (iPACK) block and compared them with those of continuous FNB amplified with iPACK block in preventing postoperative pain among patients undergoing unilateral total knee replacement (TKR) surgeries. Methodology According to a computer-generated sequence from September 2019 to June 2020, 50 American Society of Anesthesiologists grades I-III patients aged between 35 and 75 years who underwent unilateral TKR surgery were randomized into two equal groups, namely, ACB and FNB. The Timed Up and Go (TUG) and 10-minute walk tests were used to detect early ambulation (impact on quadriceps muscle). The secondary goal was to evaluate and compare opioid consumption and analgesic efficacy between the groups measured using a numeric rating scale (NRS). The demographic characteristics, technical difficulty, efficiency, safety, and comfort were compared between the two groups. Results During the postoperative period, patients in the ACB group could perform all TUG tests significantly faster than those in the FNB group. The mean get-up time in the ACB group was 39.08 ± 5.53 seconds, whereas that in the FNB group was 44.92 ± 7.10 seconds (p < 0.01). The 3-m walk time was 123.16 ± 15.90 seconds in the ACB group and 134.68 ± 13.13 seconds in the FNB group (p < 0.01). The 10-m walk time was 221.24 ± 18.82 seconds in the ACB group and 245.24 ± 21.68 seconds in the FNB group (p < 0.001). No significant difference was observed in NRS scores between the groups after the first 24 hours. The number of opioids available for consumption in both groups was equivalent. Conclusions ACB when augmented with an iPACK block is a good alternative to FNB for unilateral TKR surgeries. ACB may promote early ambulation without a reduction in analgesia when compared with FNB.

Correlation of Perioperative Atelectasis With Duration of Anesthesia, Pneumoperitoneum, and Length of Surgery in Patients Undergoing Laparoscopic Cholecystectomy.

Background During anesthesia, atelectasis is frequent, and it is also seen in critically ill individuals with a variety of underlying causes and pathologies. Objective The present study was conducted to assess whether there is a correlation between perioperative atelectasis and duration of anesthesia, pneumoperitoneum, and length of surgery in patients undergoing laparoscopic cholecystectomy. Material and methods Seventy-two American Society of Anesthesiologists (ASA) grade I-III patients of either gender undergoing elective laparoscopic cholecystectomy who met the inclusion criteria were enrolled in this observational study. The lung ultrasound (LUS) score was used to determine the amount of aeration loss. LUS scoring was performed at five predetermined time points: preoperative period (time point A), five minutes after induction (time point B), five minutes after pneumoperitoneum insufflation (time point C), end of surgery before extubation (time point D), and one hour after extubation in the postoperative room (time point E). Results At time points A, B, C, D, and E, vital parameters such as pulse rate, respiratory rate, oxygen saturation, and noninvasive blood pressure were continuously monitored and recorded. Hemodynamics remained stable, and no clinically significant changes in parameters were seen at any stage during the procedure. At each time point, the change in the LUS score was statistically significant (p-value = 0.01). Following the induction of general anesthesia, there was an increase in LUS scores, which increased further after the creation of pneumoperitoneum. Throughout the pneumoperitoneum and anesthetic periods in our investigation, the LUS score steadily climbed. Conclusion Even during short-term surgeries such as laparoscopic cholecystectomy, atelectasis can occur. The duration of pneumoperitoneum and ASA status can contribute to atelectasis.

Delayed Diagnosis of Neck Pain: Eagle Syndrome.

Eagle syndrome is a rare condition characterized by an abnormally elongated styloid process with or without abnormal direction and/or ossification of the styloid ligament. Clinically, it consists of throat and neck pain radiating to the ear. Here, we present the case of a 34-year-old female with the complaint of left-sided neck pain below the ear for the past year. The patient had tried different analgesics after seeing different doctors, but the pain did not resolve. After conducting radiological investigations at the hospital, a diagnosis of Eagle syndrome was made. The patient was treated with surgical styloidectomy, followed by subsequent remission of the symptoms.

Preprocedural ultrasound as an adjunct to blind conventional technique for epidural neuraxial blockade in patients undergoing hip or knee joint replacement surgery: A randomised controlled trial.

BACKGROUND AND AIMS: The patients undergoing total knee and hip replacement surgeries are mostly obese, more than 50 years of age with osteophytic spine and spine deformities making the blind conventional technique of regional anaesthesia more difficult. The aim of the study was to compare the role of preprocedural ultrasound scan to conventional blind technique in obese patients with osteophytic spines undergoing total knee or hip replacement surgeries in terms of technical difficulty, clinical efficacy, safety and patient comfort. METHODS: A prospective, randomised controlled trial was conducted in which 210 consenting American Society of Anesthesiologists (ASA) grade III patients, age >50 years, Body Mass Index (BMI) ≥30 kg/m2 with osteophytic spines including abnormalities undergoing joint replacement surgeries were randomised in two groups. Ultrasound group ("B") received Combined Spinal Epidural Anaesthesia (CSEA) after preprocedural lumbar ultrasound scan. In control group ("A"), CSEA was given by blind conventional technique. The primary objective was to compare the rate of successful epidural block on 1st needle insertion attempts in both the groups. The secondary objectives were to compare both groups in terms of ease, success, comfort and safety of epidural block. RESULTS: Ultrasound improved success of CSEA at 1st attempt from 74.3% in control group ("A") to 85.7% in Ultrasound group ("B") (P = 0.038). Fewer needle insertion attempts, passes and anaesthesiologist were required in ultrasound group. Pearson correlation coefficient was 0.976 using both views. CONCLUSION: Preprocedural ultrasound scan is a useful adjunct to lumbar epidural blocks in obese patients with osteophytic abnormal spines.

Erector spinae plane block: Relatively new block on horizon with a wide spectrum of application - A case series.

Erector spinae plane (ESP) block is an interfascial plane block where a local anaesthetic is injected in a plane preferably below the erector spinae muscle. It is supposed to work at the origin of spinal nerves based on cadaveric and contrast study. It has emerged as an effective and safe analgesic regional technique. It has a wide variety of applications ranging from control of acute postoperative pain to chronic pain. In this series, we report a series of six cases, which include postoperative pain management in breast, thoracic, and abdominal surgeries along with management of two chronic pain cases to illustrate the potential uses of continuous and single-shot ESP block.

Non Secretory Multiple Myeloma With HCV Infection: A Rare Case Entity.

Multiple Myeloma is a neoplasm of B cell lineage characterized by excessive proliferation of abnormal plasma cells. It is characterized by a clinical pentad of 1) anemia, 2) a monoclonal protein in the serum or the urine or both, 3) bone leisons and or bone pain, 4) hypercalcemia>11.5g/dl and 5) renal insufficiency. Non secretory multiple myeloma is a rare variant of the classic form of multiple myeloma and accounts for 1% to 5 % of all cases of multiple myeloma. The clinical presentation and radiographic findings of non-secretory multiple myeloma and multiple myeloma are the same. The diagnosis of multiple myeloma requires the demonstration of monoclonal gammopathy in the serum or urine. In non-secretory multiple myeloma, however no such gammopathy can be demonstrated, making the diagnosis more difficult. We describe a 60 year old woman who initially presented with back pain which when further investigated by complete blood count revealed hemoglobin of 13g/dl, Total Leukocyte Count of 10,890 and platelet count of 1.5 lac/cmm. Viral markers revealed HCV positive. Hypercalcemia with a serum calcium level of 12.5g/dl was also demonstrated. MRI revealed multiple lytic bony lesions. No monoclonal gammopathy was found in the serum or urine and bone marrow biopsy showed marked plasmacytosis of > 45%. We present a case of Non Secretory multiple myeloma because of its illusive nature and rare entity.

Cytological spectrum of salivary gland lesions and their correlation with epidemiological parameters.

BACKGROUND: The role fine-needle aspiration (FNA) in the diagnosis of salivary gland lesions has evolved over the years. Although clinical and radiological parameters help to narrow the differential diagnosis the tissue diagnosis still remains the gold standard. MATERIALS AND METHODS: This study is from January 2013 to December 2015 in our Department of Pathology where 170 salivary gland lesions were aspirated. The aim of the present study was to analyze adequacy rate in relation to the size of lesion and to evaluate varied cytological spectrum of salivary gland lesions with emphasis on differential diagnosis and to correlate cytological diagnosis with age, gender and anatomical site. RESULTS: The 170 cytological smears were categorized into two groups: Group 1 adequate aspirations (88.2%), Group 2 inadequate aspirations (11.7%). The adequate aspirations were subdivided as neoplastic (53.33%) and nonneoplastic (46.66%). The distribution of the various neoplastic lesions (80; 53.33%) were 66 (82.5%) benign, 12 (15%) were malignant and 2 (2.5%) were suspicious of malignancy. Among benign neoplasms, the pleomorphic adenoma (62; 93.3%) was the most frequent followed by Warthins tumor (4; 6%). The most common malignant neoplasms were adenoid cystic carcinoma (6; 50%), followed by mucoepidermoid carcinoma (4; 33.3%), malignant lymphoma (1; 8.3%) and metastatic carcinomatous deposits (1; 8.3%). In two cases, cytological picture indicated suspicion for malignancy however specific tumor typing could not be done. The neoplasms occurred more frequently in the parotid gland (65%), followed by submandibular gland (21.3%) and minor salivary glands (13.8%). The nonneoplastic lesions (70) included 68.6% cases of chronic sialadenitis, 17.1% cases were reported as mucocele, 11.4% cases of acute sialadenitis 2.9% cases as tubercular granulomas. CONCLUSION: FNA cytology provides useful information on the management of salivary gland lesions and prevents unnecessary surgery in cases of nonneoplastic lesions and identification of malignancy helps the surgeon in deciding type and extent of surgery.

Preoperative Peripheral Blood Count in Breast Carcinoma: Predictor of Prognosis or a Routine Test.

Background. Peripheral blood count is the first investigation to be done in every patient before surgery. As strong relationship exists between cancer and immune response of the body, clinical stage at presentation and altered hematological parameters can influence the progression of cancer and vice versa. Settings and Design. It is a case control study of total 50 cases (35 cases of carcinoma breast and 15 cases of benign breast disease). Methods. A case control study was carried out; 35 cases of breast cancer patients were taken prior to surgery and chemotherapy with 15 cases of benign breast disease as control. Clinical staging according to the tumor, node, and metastasis classification (TNMc) was done and was correlated with complete blood count (CBC). Results. All the cancer patients were females with overall mean age of 47.96 ± 13.84 years. Amongst all altered blood parameters, correlation of absolute lymphocytic count (p value 0.001) with TNMc staging was found significant. Particularly, decrease in absolute leucocytic count was observed with increase in stage of breast carcinoma. Conclusions. The stage-specific mean values of absolute lymphocytic counts of preoperative breast cancer patients can be used as an economical tool to know the evolution of disease.

Diagnostic value of bone marrow aspiration and biopsy in routine hematology practice.

BACKGROUND: The bone marrow is frequently involved in variety of cases presenting with hematological and non-hematological disorders, which are diagnosed by two separate but interrelated techniques such as bone marrow aspiration (BMA) and bone marrow biopsy (BMB). AIM: This study was aimed to assess the diagnostic value of the BMA and BMB and role of both the procedures to reach final diagnosis when done simultaneously. SETTINGS AND DESIGN: It was a prospective study. The findings of BMA smears were correlated with BMB sections and data obtained was analysed. MATERIALS AND METHODS: BMA and BMB were performed on 50 patients. Criteria of inclusion included the main indications for performing this procedure, the availability of full medical records and patient consent. The patients had a male to female sex ratio of 1.6:1 and a wide age range from 4 years to 74 years. RESULTS: In the present study, the main indications for bone marrow examination were categorized. Out of 50 cases studied, in 23 cases, a strong positive correlation between BMA and BMB was noted. However, it was found that in the cases of aplastic anaemia, different phases of myeloproliferative neoplasm (MPN), multiple myeloma, tubercular granulomas and hemato-lymphoid neoplasm, involvement of the marrow was detected better in bone marrow biopsies. CONCLUSION: The study concludes that preparations of aspirate and trephine biopsy are easy, rapid and complementary to each other in majority of the lesions. The advantage of both the procedures done together enabled us to study the cytomorphology of the cells along with the pattern of distribution of the cells depending on the cases, hence help in making the diagnosis accurately.