Physiological and Anesthetic Considerations of Safe and Optimal Pneumoperitoneal Pressures for Laparoscopic Surgeries in Children.

Context: In the era of minimally invasive surgeries, pediatric laparoscopic surgeries are now becoming the standard of care. Aim: In this study, we aim to determine the safe and optimal pneumoperitoneal pressures (PPs) for laparoscopic surgery in children aged 1-5 years, along with the technical ease for the surgeon. Settings and Design: Prospective, randomized, single-blinded study was conducted at SGPGI Lucknow. Materials and Methods: Children aged 1-5 years were randomized into Group I (n = 24): PP = 6-8 mmHg and Group II: (PP) = 9-10 mmHg. Hemodynamic, ventilatory, and blood gas changes were measured before CO2 insufflation (T0), 20 min after insufflation (T1), before desufflation (T2), and 10 min after desufflation (T3). Surgeon's technical ease of surgery, postoperative pain, the requirement of rescue analgesia, time to resume feeding, and complications were recorded and analyzed. Statistical Analysis Used: Paired t-test, Mann-Whitney test, and Wilcoxon signed-rank test were used for nonparametric/parametric data. Chi-square/Fisher's test was used for nominal data. Results: Partial pressure of CO2 (PaCO2) was significantly higher in Group II at T1, T2, and T3, requiring frequent changes in ventilatory settings. Postoperative pain scores were higher in Group II at 1, 6, and 12 h, requiring rescue analgesia. Surgeon's scores and hemodynamics were similar in both groups. Conclusions: Higher PP in Group II caused significant changes in PaCO2, end-tidal CO2, and postoperative pain requiring rescue analgesia, but blood gas changes were clinically insignificant and there were no significant changes in hemodynamic parameters. Since the surgeon's ease of performing surgery was similar in both groups, we recommend that laparoscopy in children aged 1-5 years can be started with lower PPs of 6-8 mmHg, which can be increased if needed based on the surgeon's comfort and the patient's body habitus.

Incidence of Different Characters of Neuropathic Pain in Cancer Patients Coming to Tertiary Care Centre in North India Over A Period of 1 Year - An Observational Study.

Objectives: Pain is classified as nociceptive, neuropathic, or nociplastic. Neuropathic pain presents as variable phenotypes (characters) based on specific aetiology and pathophysiology. This study aimed to find out among cancer patients the incidence of different phenotypes of neuropathic pain and form specific phenotypic clusters based on the underlying neurophysiology and association of sensory profile with various organ systems - A prospective observational study. Materials and methods: The Institutional Ethical Committee clearance (IEC code: 2020-49-MD-EXP-15) https://ctri.nic.in/Clinicaltrials/showallp.php?mid1=44886&EncHid=88651.15716&userName=CTRI/2020/09/027964 approval was obtained. After written and informed consent, patients of age group 18-80 years, registering in the pain and palliative outpatient department or radiotherapy department with complaints of pain and not taking any anti-neuropathic pain medications, were enrolled. They were assessed using Leeds assessment of neuropathic symptoms and signs (LANSS) pain score, and a score of >12 was eligible for assessment of neuropathic pain phenotypes. Results: Out of 210 cancer patients complaining of pain, a neuropathic component with LANSS >12 was found in 73 (34.76%). The most predominant phenotypes, allodynia> tingling> pricking = burning, were found in 72.60%, 56.16%, and 43.84% of patients, respectively. Phenotypes were clustered into Nodes 1 and 2 based on clinically significant separation of phenotypes. Node 1 had neuropathic pain of spontaneous origin found predominantly in gastrointestinal tract (GIT) and genitourinary tract (GUT) cancers. Node 2 had stimulus-evoked negative and positive characters which occurred in head and neck, thoracic, and spinal metastatic cancers. Conclusion: Careful patient assessment reveals the incidence of neuropathic pain in 34.76%; allodynia and tingling astable the most prominent phenotypes. Broadly, sensory characters were clustered into spontaneous and stimulus-evoked sensations with GIT and GUT cancers presenting with Node 1 symptoms.

Comparative Evaluation of Retrocrural versus Transaortic Neurolytic Celiac Plexus Block for Pain Relief in Patients with Upper Abdominal Malignancy: A Retrospective Observational Study.

AIM: To compare retrocrural versus transaortic techniques for neurolytic celiac plexus block (NCPB) in patients suffering from upper abdominal malignancy. METHODS: In this retrospective observational study between October 2013 and April 2015, 64 patients with inoperable upper abdominal malignancy received fluoroscopy-guided percutaneous NCPB in our institute. Their case files were reviewed and the patients were divided into two groups depending on the technique used to perform NCPB: retrocrural (Group R; n = 36) versus transaortic (Group T; n = 28). The primary outcome measure was pain as assessed with a numeric rating scale (NRS) from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses in each group, and complications if any. These were noted and analyzed prior to intervention and then on day 1, weeks 1, 2, 3, and months 1, 2, 3, 6 following NCPB. RESULTS: Patients in Group R had significantly reduced NRS pain scores at week 1, 2, 3, month 1 and 2 as compared to Group T (P < 0.05). Morphine consumption also reduced significantly in Group R at day 1, week 1, 2, and 3 (P < 0.05). QOL was found to be comparable between the groups, and no major complications were noted. CONCLUSION: Retrocrural NCPB provides superior pain relief along with a reduction in morphine consumption as compared to transaortic NCPB in patients with pain due to upper abdominal malignancy.

To compare the efficacy of the between-the-fingers grip with the conventional pen-holding grip to hold an endotracheal tube for orotracheal intubation: A randomised controlled trial.

Background and Aims: Correctly holding the endotracheal tube (ETT) is essential for successful tracheal intubation. The study's primary objective was to compare the between-the-fingers grip with the conventional pen-holding grip regarding the number of attempts required for orotracheal intubation and usage of external aids. Methods: Three hundred patients undergoing elective surgeries under general anaesthesia were randomised according to the method to hold the ETT to Group C (conventional grip) and Group M (modified, between-the-fingers grip) during oro-tracheal intubation. A designated anaesthetist blinded to the groups performed laryngoscopy in all the patients, and difficult Cormack-Lehane grade 3b and 4 (n = 24) were excluded. Then, the group was revealed to the anaesthetist, and intubation was done accordingly; the number of attempts, use of backward upward rightward pressure (BURP), and time taken were noted. The sample size was estimated using the software G*Power version 3.1.9.2. Statistical Package for Social Sciences, version 23 (SPSS-23, IBM, Chicago, USA) was used for data analysis. Results: Single-attempt intubation was comparable between the groups (99.3% versus 97.2%, P = 0.197). In contrast, the external assistance as BURP (0.75% versus 6.99%, P = 0.009) and the time taken for intubation (P = 0.008) were reduced in group M significantly. Conclusion: The between-the-fingers grip seems as effective as the standard grip to hold the ETT during intubation. However, it proved to be better as it can reduce the requirement for external assistance in BURP.

3D Virtual Bronchoscopy as an Aid to Airway Management in a Patient with Anterior Mediastinal Mass.

ABSTRACT: Mediastinal masses pose one of the great challenges for any anesthesiologist during airway maintenance, underlining the need to devise a well-formulated plan to avoid perioperative complications. As a general rule, such patients are managed with spontaneous ventilation without the use of muscle relaxants and awake intubation. We report a case of a 66-year-old male with severe dyspnea, having a very large invasive anterior mediastinal mass, causing left lung collapse for urgent debulking surgery. The tracheobronchial compromise was ruled out using three-dimensional reconstruction on computed tomography imaging (virtual bronchoscopy) and that helped in using general anesthesia with muscle relaxation for subsequent endotracheal intubation and surgery.

Robotic computed tomography-guided celiac plexus neurolysis: our experience of technique and outcomes.

Aim: We report the use of robot assistance for computed tomography-guided celiac plexus neurolysis for the first time. Materials & methods: Four patients of upper abdominal cancer with intractable pain despite opioids were positioned prone on the PET-computed tomography scanner, which measured the accurate coordinates for the entry, depth and angle of the target point. The robot positioned its arm over the patient in accordance with the set needle path. The physician manually inserted needle through it and injected 20 ml of 0.75% alcohol after dye confirmation. Results: Significant reduction in pain scores and oral morphine consumption were observed in patients during 3 months follow-up. Conclusion: The robot precisely orients and helps in accurate placement of the needle through the robotic arm.

Smartphone Use among Anesthesiologists during Work Hours: A Survey-Based Study.

Context: Smartphone use has revolutionized life in all spheres, including the medical field. Smartphones provide immense opportunities but may also lead to negative consequences due to the element of distraction. In the medical profession and more so among anesthesiologists, multitasking has become very common, but the presence of mind is equally important. This study attempts to analyze the smartphone practices and trends among anesthesiologists during work hours in our country. Aims: The study aimed to identify recent trends and practices of smartphone use among anesthesiologists during working hours and its distribution as per designation and institutions. It also intends to determine the purposes of smartphones and their impact on patient care. Settings and Design: Online survey consisting of open-ended multiple-choice questions was conducted and circulated as Google Forms via E-mail and WhatsApp. Subjects and Methods: This survey was conducted to compare the respondents' views as per designation and workplace distribution. In addition, participants were asked about the current practices in smartphone use at their workplace, purposes of use, time spent on smartphones, and any negative medical consequences faced due to the same. Statistical Analysis Used: One-way ANOVA test was used to compare the means between the groups. Chi-square test/Fisher's exact test was used to compare the proportions. Results: Two hundred and sixteen (54%) were resident doctors, whereas 184 (46%) were consultants. Most of the respondents were young, with a mean age around 36 years. 31.5% of the residents used smartphones very often during anesthetized patient care compared to 10.3% of the consultants. Purposes of using smartphones were multiple, with phone calls (100%) being the most common followed by WhatsApp messaging (79.2%). 86.1% of the residents, as compared to 61% of the consultants, had anesthesia/intensive care unit-related apps on their smartphones. There was almost an equivocal response to how the smartphone has impacted patient care. 50.9% of the residents and 43% of the consultants felt improved patient care, whereas 38% of the residents and 43.5% of the consultants believed it had worsened. Conclusion: There was no clear-cut consensus whether smartphone use improved or worsened patient care. On the one hand, there can be distractions leading to adverse medical consequences, while on the other hand, the use of medical apps has been made possible because of the handy and easily accessible smartphones. Thus, the use of smartphones may be carried out with a sense of responsibility by the anesthesiologists during work hours.

Impact of Postoperative ABG Analysis and ICU Weaning Protocol in Surgical Outcome of Atlanto-Axial Dislocation: It's not the Towering Sail, but the Unseen Wind that Moves the Ship.

Background: The outcome in patients of atlanto-axial dislocation (AAD) depends on multiple factors like preoperative optimization, intraoperative distractio and cord manipulation. Certain unfocussed factors such as respiratory reserve and compensatory acclimatization to hypoxia warrant consideration. Aims: The purpose of this study is to find the association of postoperative arterial blood gas (ABG) analysis and respiratory reserve in patients of AAD with clinical outcome. Study Design: We retrospectively analyzed the available records of patients, operated for AAD, at our institute (n = 66), from January 2014 to November 2018. Materials and Methods: Preoperative pulmonary function test (PFT) and the postoperative ABG analysis was noted. Timing of extubation, duration of intensive care unit (ICU) stays, and clinical outcomes (Nurick grade) were noted from the inpatient record and the last outpatient follow up. An independent t-test and analysis of variance were used to find significance. Results: In total, 41% (n = 27) patients had body mass index of less than 18.5, and 50% (n = 33) had breath holding time of less than 20 minutes. There was improvement in mean Nurick grade from 3.17 ± 0.8 to 2.76 ± 0.7 in follow up. A trend suggesting that patients with poor preoperative PFT has more ICU duration and worse outcome. In patients with mild acid-base disorders, extubation was possible within 24 hours. Out of 26 patients with ICU duration less than 2 days, 23 patients had "good" outcome, whereas ten out of 40 patients with ICU duration of more than or equal to 2 days had "bad" outcome (P = 0.00). Conclusion: Patients having moderate to severe primary or mixed acid-base disorder have a probability of re-intubation or delayed extubation. A strong correlation was seen with the novel grading system (grade >6 had worse outcome).

Comparative Evaluation of Efficacy of Fluoroscopy and Ultrasound for Iliopsoas Block: A Randomised Trial.

OBJECTIVE: To compare analgesic efficacy, improvement in the quality of life, psychology and learning curve for iliopsoas (IP) injection using ultrasound (US) versus fluoroscopy (FL). METHODS: Thirty-six patients with chronic low back pain secondary to IP myofascial pain were randomly allocated into two groups and were given IP injection in prone position, using either FL or US as a guide. Pain scores were assessed using numerical rating scale (NRS); learning curve was evaluated by the number of attempts, time taken and subjective ease of performing the procedure. The psychological and quality of life assessment were done using Depression Anxiety Stress Scale (DASS) and Oswestry Disability Index (ODI), respectively. RESULTS: FL and US guided IP injection had equianalgesic efficacy with a decrease in preprocedure NRS pain scores from mean value of 7.06 6 0.24 and 6.78 6 0.24, respectively, to 2.22 6 0.29 and 1.78 6 0.26 (at 24 hours), 1.50 6 0.22 and 1.50 6 0.23 (1 week), 0.50 6 0.12 and 0.56 6 0.15 (4 weeks) and 0.33 6 0.11 and 0.44 6 0.15 (12 weeks) (P < .001). The learning curve was easier for US intervention with average attempts of 1-2 compared to 1-3 for FL. The average time taken to perform IP intervention was lesser for US group. The improvement in DASS and ODI was comparable in both groups. CONCLUSION: FL and US both are effective modalities for IP muscle injection as they provide equal relief from pain, disability and psychological stress. US guided IP injections are easier to learn and perform in comparison with FL.

Evaluation of postoperative pain in patients undergoing modified radical mastectomy with pectoralis or serratus-intercostal fascial plane blocks.

BACKGROUND: Regional nerve blocks are an integral part of multimodal analgesia and should be chosen based on their efficacy, convenience, and minimal side effects. Here, we compare the use of pectoral (PEC II) and serratus-intercostal fascial plane (SIFP) blocks in breast carcinoma cases undergoing modified radical mastectomy (MRM) in terms of the postoperative analgesic efficacy and shoulder mobility. METHODS: The primary outcome of this prospective controlled study was to compare the postoperative static and dynamic pain scores, and the secondary outcome was to assess the shoulder pain, range of shoulder joint motion, and hemodynamic parameters. Sixty patients were randomly allocated to three groups and given general anesthesia. All patients received paracetamol, diclofenac, and rescue doses of tramadol based on the Institute's Acute Pain Service (APS) policy. No block was performed in group C (control), whereas groups P and S received PEC II and SIFP blocks, respectively, before surgical incision. RESULTS: The groups were comparable in terms of age, weight, height, and body mass index distribution (P > 0.05). Dynamic pain relief was significantly better 12 and 24 h postoperatively in groups P (P = 0.034 and P = 0.04, respectively) and S (P = 0.01 and P = 0.02, respectively) compared to group C. Shoulder pain relief and shoulder mobility were better in group S, while the hemodynamic parameters were more stable in group P. CONCLUSIONS: Both SIFP and PEC blocks have comparable dynamic and static pain relief with better shoulder pain scores in patients receiving SIFP.

Evaluation of Serratus Anterior Plane Block for Pain Relief in Patients Undergoing MIDCAB Surgery.

OBJECTIVE: The minimally invasive direct coronary artery bypass (MIDCAB) surgery is associated with severe chest pain in the first 2 to 3 postoperative days; this may delay the patient recovery. In this randomized controlled trial we evaluated the role of serratus anterior plane (SAP) block for postoperative pain relief in patients undergoing MIDCAB surgery. METHODS: Patients undergoing MIDCAB surgery were randomized into 2 groups of 25 each; SAP group received 20 mL of 0.2% ropivacaine with 1 µg/mL fentanyl as bolus followed by infusion at 8 mL/h; control group received saline for both bolus and infusion. Primary outcome measure was postoperative pain when supine, and during deep inspiration, coughing, and patient movement; secondary outcome measures were requirement of postoperative intravenous fentanyl and opioid-related side effects. All patients were followed at 6-hourly intervals for 48 hours in the postoperative period. Results were analyzed by the Student's t -test, χ 2 test, Mann-Whitney U-test and Kruskall-Wallis test. A P-value <0.05 was considered significant. RESULTS: The 2 groups were similar with respect to patient characteristics. Static and dynamic pain visual analog scale scores were significantly reduced in the SAP group as compared to the control group at most of the time points of assessment (P < 0.05). Patient-controlled fentanyl requirements were reduced in the SAP group as compared to control group on the second postoperative day (P < 0.05). CONCLUSIONS: SAP block reduced the postoperative pain scores and opioid requirements in patients undergoing MIDCAB surgery.

Double blind randomized control trial to evaluate the efficacy of ketoprofen patch to attenuate pain during venous cannulation.

BACKGROUND: Venipuncture pain is an uncomfortable suffering to the patient. It creates anxiety, fear and dissatisfaction. The ketoprofen transdermal patch is a proven treatment for musculoskeletal and arthritic pain. We planned this study to evaluate the efficacy of the ketoprofen patch to reduce venipuncture pain. METHODS: Two hundred adult patients, aged 18-60 years, of either sex, ASA grade I or II, were enrolled. Presuming that therapy would decrease venipuncture pain by 30%, a power calculation with α = 0.05 and ß = 0.80 required enrollment of at least 24 patients into each group. However, 100 patients in each group were recruited. Group I (Control) received a placebo patch; Group II (Ketoprofen) received a 20 mg ketoprofen patch. A selected vein on the dorsum of the patient's non-dominant hand was cannulated with 18 g intravenous cannula 1 h after the application of the respective patch. Assessment of pain was done by a 10 cm visual analogue scale (VAS) of 0-10, where 0 depicts "no pain" and 10 is "the worst imaginable pain". The venipuncture site was assessed for the presence of skin erythema, swelling and rashes at 12 h, 24 h and at the time of decannulation. RESULTS: Incidence of pain was 100% (94/94) in the control group as compared to 93% (85/91) in the ketoprofen group. The severity of the venipuncture pain was 6 (2) and 2 (2) for control and ketoprofen groups respectively (P < 0.05). CONCLUSIONS: Application of a ketoprofen patch at the proposed site of venipuncture one hour before the attempt is effective and safe for attenuating venipuncture pain.

Prevention of hypotension induced by combined spinal epidural anesthesia using continuous infusion of vasopressin: A randomized trial.

BACKGROUND: Central neuraxial blockade (CNB) is an established technique of providing anesthesia for surgeries of the lower limb and abdomen. Hypotension is the most common side effect of CNB. It was hypothesized that by supplementing the initial burst of vasopressin following hypovolemia, hypotension following combined spinal epidural anesthesia (CSEA) could be avoided. MATERIALS AND METHODS: A total of 122 patients undergoing lower limb and abdomen surgeries were included in the study, with 61 patients randomized into two groups - I and II. Patients in Group I received infusion of normal saline as soon as CSEA was applied. When systolic blood pressure (SBP) decreased to <90 mmHg, they received a 6 mg bolus of mephentermine to counteract hypotension. Patients in Group II received a continuous infusion of vasopressin as soon as CSEA was applied. If despite maximum dose of vasopressin, SBP dropped to < 90 mmHg, then intravenous mephentermine was administered to counteract hypotension. Hemodynamic parameters and side effects were noted. RESULTS: Level of block attained in both groups was comparable in terms of dermatomal height. The mean SBP and mean arterial pressure values of Group I were significantly lower than in Group II in the initial 14 min. Diastolic BP was also significantly lower in Group I. Heart rate was found to be lower in Group II, especially after 30 min (P < 0.05). CONCLUSION: Maintaining plasma levels of the physiological burst of vasopressin helps to avoid hypotension following neuraxial blockade. Continuous infusion of vasopressin at 1-3 U/h can prevent hypotension following neuraxial blockade.

An unusual cause of unilateral facial injuries caused by horseshoe headrest during prone positional craniovertebral junction surgery.

Pressure injuries are an accepted complication of prone positioning during the neurosurgical procedures. Horseshoe headrest are intended to reduce the incidence and severity of such injuries by allowing limited areas of contact between the skin of dependent areas of contact and the supporting surfaces. We report a case where a patient positioned prone over a horseshoe headrest developed inadvertent unilateral facial pressure injuries following a 6-h long craniovertebral junction (CVJ) surgery. We attempt to highlight this complication, analyze its causation, and briefly review the existing literature related to similar reported injuries.

Fluoroscope-guided celiac plexus block in a pregnant patient: a case report.

A 28-weeks gestation pregnant patient with chronic pacreatitis and severe abdominal pain leading to impaired nutrition is presented. After detailed consideration of the case, fluoroscopic-guided celiac plexus neurolysis was performed. The block was performed using the transaortic approach as it reduces radiation exposure.

Evaluation of Efficacy of Bone Scan With SPECT/CT in the Management of Low Back Pain: A Study Supported by Differential Diagnostic Local Anesthetic Blocks.

INTRODUCTION: Conventional radiologic modalities provide details only about the anatomic aspect of the various structures of the spine. Frequently the structures that show abnormal morphology may not be the cause of low back pain (LBP). Functional imaging in the form of bone scan along with single photon emission computerized tomography (SPECT/CT) may be helpful in identifying structures causing pain, whether morphologically normal or not. The objective of this study is to evaluate the role of bone scan with SPECT/CT in management of patients with LBP. METHODS: This is randomized double-blinded controlled study performed on 80 patients with LBP aged 20 to 80 years, ASA physical status I to III. Patients were randomized into bone scan and control groups consisting of 40 patients each. On the basis of the clinical features and radiologic findings a clinical diagnosis was made. After making a clinical diagnosis, the patients in bone scan group were subjected to bone scan with SPECT/CT. On the basis of the finding of the bone scan and SPECT/CT, a new working diagnosis was made and intervention was performed according to the new working diagnosis. Diagnostic blocks in the control group were given based on clinical diagnosis. Controlled comparative diagnostic blocks were performed with local anesthetic. The pain score just after the diagnostic block and at the time of discharge (approximately 4 h later) was recorded; the pain relief was recorded in percentage. RESULTS: In both the groups, sacroilitis was the most common diagnosis followed by facet joint arthropathy. The number of patients obtaining pain relief of >50% was significantly higher in the bone scan-positive group as compared with the control group. Three new clinical conditions were identified in the bone scan group. These conditions were multiple myeloma, avascular necrosis of the femoral head, and ankylosing spondylitis. CONCLUSIONS: Bone scan with SPECT/CT was found to complement the clinical workup of patients with LBP. Inclusion of bone scan with SPECT/CT in LBP management protocol can help in making a correct diagnosis. At times it might bring out some new information that may be vital for further management of the patients with LBP.