A Comparison Between Dexamethasone and Clonidine as Adjuvants to Levobupivacaine in the Supraclavicular Approach to the Brachial Plexus Block: A Double-Blind Study.

OBJECTIVE:  The objective of this clinical study is to compare the efficacy of adding dexamethasone or clonidine as an adjuvant drug to levobupivacaine in supraclavicular brachial plexus block (BPB) with regard to the onset and duration of sensory and motor blocks along with duration of postoperative analgesia. BACKGROUND:  Brachial plexus block (BPB), with or without general anesthesia, has been used widely for multiple upper limb surgical procedures, by virtue of its efficacy in terms of cost-effectiveness, efficiency, safety margins, and good postoperative analgesia. Various adjuvant drugs have been described to potentiate the analgesic effect of local anesthetic agents such as epinephrine, clonidine, dexamethasone, dexmedetomidine, or midazolam. MATERIALS AND METHODS: This is a prospective, randomized, double-blind study in which a total of 90 American Society of Anesthesiology (ASA) physical status I and II patients of either sex, aged between 18 and 60 years, were scheduled for elective upper limb surgical procedures under supraclavicular BPB. They were divided into three equivalent randomized groups with 30 patients in each group. The patients were administered either normal saline 2 mL (in group L) or clonidine 0.5 mcg/kg body weight (in group LC) or dexamethasone 8 mg (in group LD) with 30 mL of 0.5% levobupivacaine. The time of onset and duration of sensory and motor blockades along with the time duration of analgesia were compared. RESULTS: All groups were equivalent as per demographic data. The time duration for onset of sensory and motor blocks was comparable among all three included groups (12.77±2.60 minutes and 20.80±3.25 minutes, 15.93±2.08 minutes and 22.43±3.07 minutes, and 12.57±2.62 minutes and 22.47±3.10 minutes for group L, LC, and LD, respectively). The time duration of analgesia and motor blockade was significantly prolonged in the dexamethasone group (1195.33±50.01 minutes and 1173.17±43.57 minutes) and moderately prolonged in the clonidine group (696.33±36.74 minutes and 674.67±34.33 minutes) when compared to levobupivacaine group (416.33±35.98 minutes and 397.00±35.12 minutes), and the difference was statistically significant (p<0.001). CONCLUSION:  Dexamethasone appears to be a superior adjuvant drug to clonidine for brachial plexus block via supraclavicular approach as it provides prolonged duration of motor block with lesser requirement of postoperative analgesia and lack of adverse effects.

Neuropsychiatric Outcomes in Intensive Care Unit Survivors.

BACKGROUND: Over the last two decades, there has been phenomenal advancement in critical care medicine and patient management. Many patients recover from life-threatening illnesses that they might not have survived a decade ago. Despite a decrease in mortality, these survivors endure long-lasting sequelae like physical, mental, and emotional symptoms. METHODS: Patients after intensive care unit (ICU) discharge were assessed in a follow-up outpatient department (OPD) clinic for anxiety, stress, and depression. Patients were asked to fill out the questionnaires Depression, Anxiety and Stress Scale-21 (DASS-21) and Short Form-36 (SF-36) for assessment of health-related quality of life (HRQOL) at 4th, 6th, and 8th months after discharge. ICU data were recorded, including patients' demographics, severity of illness and length of stay, and duration of mechanical ventilation. Patients who failed to follow-up in OPD on designated dates were assessed telephonically. RESULTS: Depression showed a positive, strong, and moderate correlation between length of stay and mechanical ventilation duration. A positive correlation was found between stress and length of stay and duration of mechanical ventilation. A positive strong correlation was found between anxiety and length of ICU stay, and a moderate positive correlation was found between anxiety and duration of mechanical ventilation. A weak correlation was found between age and neuropsychiatric outcomes. CONCLUSION: The severity of depression, anxiety, and stress was significantly higher at four months compared to six months. Severity decreased with time. Prolonged ICU stay increased levels of anxiety, depression, and stress. HRQOL improved from four to six months.

Postgraduate training in anaesthesiology - A modular curriculum.

The primary objective of postgraduate medical education is to produce specialists who provide highest quality of health care to suffering patients and return them to the community in the most functional capability. The secondary objective is to advance the cause of science through research and training. A postgraduate, after undergoing the required training in anaesthesiology, should be able to recognise the health needs of the community and apply cognitive and psychomotor skills to provide optimal anaesthetic care. Additionally, the anaesthesiologist should function as a perioperative physician being adept in perioperative care, pain medicine and critical care medicine. The 3-year postgraduate curriculum comprises experience in basic, subspeciality and advanced anaesthesia training. This structured training programme with a curriculum of increasing difficulty and learning incorporates ascending grades of difficulty, posing a challenge to the trainee's intellect and technical skills. Experience in basic anaesthesia training is aimed to lay stress on basic and fundamental aspects of anaesthetic management. Subspeciality anaesthesia training is needed to lay stress on the theory, special considerations and practice of subdisciplines of anaesthesiology. This document proposes a modular-structured, continuous, objectively evaluated, systematic training process that is monitored frequently and periodically, such that the trainee, at the end of training, is capable of appropriate anaesthetic management of disease conditions in a wide variety of situations.

Effect of Deferasirox on Shunt Fraction During Thoracic Surgery With One-Lung Ventilation: A Randomized Controlled Study.

Context Deferasirox, an iron chelator, can potentially reduce intraoperative right-to-left shunt and improve oxygenation in patients undergoing thoracic surgery requiring one-lung ventilation (OLV) by potentiating hypoxic pulmonary vasoconstriction (HPV). Aim The aim was to determine the effect of deferasirox on the intraoperative shunt fraction (SF) of patients undergoing thoracic surgery using OLV. Study design and settings This was a prospective, single-blind, randomized, controlled study. The study was conducted at a tertiary-care hospital. Methods Before surgery, 64 patients were allocated to two groups comprising 32 patients each. Group D patients were administered deferasirox, while those in group C were given a placebo. We included patients with the American Society of Anesthesiologists physical status III or IV, aged 18-60 years, undergoing elective thoracic surgery needing OLV. SF was the primary outcome variable. Secondary outcome variables were arterial oxygen tension (PaO2), peripheral oxygen saturation (SpO2), the ratio of PaO2 and inspired oxygen concentration (P/F), and complications such as desaturation episodes, hypotension, and tachycardia. Results Baseline and postoperative values of outcome variables were statistically similar in both groups. Intraoperative values of SF were lower and PaO2, SpO2, and P/F were higher in group D. The incidence of intraoperative desaturation was lower in group D. Conclusion We conclude that pre-treatment with deferasirox reduces intraoperative SF and improves oxygenation during thoracic surgery using OLV.

High-Flow Nasal Cannula as an Alternate Weaning Strategy: A Randomized Controlled Trial.

Background Extubation failure is associated with increased morbidity and poor outcomes. This study aimed to ascertain the effectiveness of a high-flow nasal cannula (HFNC) as a weaning method compared to conventional weaning. Methodology A total of 60 mechanically ventilated patients, aged 18-65 years, who were ventilated for 48 hours and whose underlying pathology had either resolved or was improving, were enrolled in this study. They were randomized in a 1:1 ratio to participate in the HFNC weaning method or receive conventional weaning. Patients in Group A were extubated and oxygen was provided via HFNC. Group B patients were given a spontaneous breathing trial (SBT) per the standard protocol and extubated after a successful SBT. Results Weaning failure was found in five patients and was higher in the conventional group (three patients in the conventional group and two patients in the HFNC group). The duration of stay of patients in intensive care units was significantly higher in the conventional group than in the HFNC group. Conclusions HFNC is a better alternative to conventional weaning through SBT.

A randomized controlled trial comparing Macintosh laryngoscope and Airtraq video laryngoscope for endotracheal intubation in patients with thyroid swelling: Competing the convention.

Background: Patients with thyroid swelling are anticipated difficult airway due to the anatomical complications associated with it leading to restricted neck movements and distorted laryngeal anatomy. The aim of this randomized prospective study was to compare Macintosh laryngoscope and Airtraq video laryngoscope for endotracheal intubation in patients with thyroid swelling. Methods: Eighty adult American Society of Anesthesiologist (ASA) grades I-II patients were taken and randomly divided into two groups of 40 patients in each. After induction of general anesthesia, tracheal intubation was done with either of the technique using a flexometallic tube. Time taken for intubation, hemodynamic variations during and after intubation, any optimization maneuver used during intubation, Cormack-Lehane score, Percentage of Glottic Opening (POGO score), Intubation Difficulty Score (IDS), and postoperative airway symptoms were noted. Results: Mean time required for intubation with Airtraq was more than Macintosh; P = 0.003. But Cormack-Lehane score, IDS score, and POGO score were better in the Airtraq group. Hemodynamic variations in both groups were comparable. Optimization maneuver required and postoperative airway symptoms were more in the Macintosh group. Conclusion: In patients with thyroid swelling, Airtraq video laryngoscope provides better visualization of the glottis, requires less manipulation during intubation, and less post-operative complications than Macintosh laryngoscope but requires significantly more time for intubation.

Comparison of Continuous Infusion of Ropivacaine and Fentanyl With Intermittent Bolus Doses of Ropivacaine and Fentanyl for Epidural Labor Analgesia: A Randomized Open-Label Study.

Background The purpose of this study was to compare the efficacy of continuous epidural infusion with intermittent bolus doses for labour analgesia using ropivacaine 0.2% and opioids. Methods In this study, 70 primigravida patients were randomly divided into two groups of 35 each. Both groups received a loading dose of 10ml of 0.2% ropivacaine and 1µg/ml fentanyl in 5ml incremental doses while monitoring blood pressure and heart rate. Subsequently, Group I received a continuous epidural infusion of 0.2% ropivacaine with fentanyl at 10ml/hr, while Group II received 10 ml of 0.2% ropivacaine with fentanyl in bolus form every hour manually, with the first dose given after one hour of the initial loading dose. A rescue bolus dose of 5ml of 0.2% ropivacaine was given in both groups when they complained of breakthrough pain (VAS score >3). An additional 5ml bolus dose was given in both groups at the time of crowning. The blood pressure, heart rate, and severity of pain using the visual analogue scale (VAS) were assessed. Total drug volume utilized, the number of bolus doses, duration of the first and second stage of labour, rate of instrumental delivery and cesarean section, and neonatal Apgar scores were also recorded. Results The total volume of drugs consumed and the number of boluses required for breakthrough pain were both significantly lower in Group II. There was a similar decrease in hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) from baseline in both the groups with no significant difference between them. The onset of analgesia was significantly faster in Group I with both groups achieving optimum analgesia (VAS ≤ 3) within 20 minutes of the loading dose. Maternal motor blockade scores, the duration of the first and second stage of labour, the rate of instrumental delivery, cesarean section, and neonatal Apgar scores, did not show any statistically significant difference between the two groups. Conclusion Both techniques, i.e. continuous epidural infusion and intermittent epidural boluses are effective for providing labour analgesia. But consumption of drugs and episodes of breakthrough pain was higher in the continuous infusion group (Group I).

A Comparative Study of the ProSeal Laryngeal Mask Airway Versus Endotracheal Tube in Neonates With Anorectal Malformations.

BACKGROUND: Laryngeal mask airways (LMAs) are widely used in paediatric anaesthesia. However, LMA use in neonatal age groups (younger than seven days) is limited because many anaesthesiologists prefer to use endotracheal tube in neonates. In this study, we compared the ProSeal LMA and endotracheal tube by measuring their performance, including ease of insertion via number of attempts for placement of device, total effective time for intubation and extubation, hemodynamic responses and perioperative complications. METHODS: In this prospective randomized study, 70 patients (neonates) weighing >2.5 kg, with American Society of Anaesthesiologists (ASA) classification grade 4 requiring emergency surgery for anorectal malformation were enrolled and divided into two groups. After induction, patients' airways were secured with either ProSeal LMA size 1 (Group I) or endotracheal tube (Group II). Anaesthesia was maintained on oxygen and sevoflurane with muscle relaxant atracurium. RESULTS: Demographic and surgical data were similar between the two groups. The ProSeal LMA insertion time was shorter than endotracheal intubation. Hemodynamic variations were less in the ProSeal LMA group as compared to the endotracheal tube group. The total time for removal of airway devices from the end of surgery for the ProSeal group was lower than that for the endotracheal intubation group. Postoperative complications were less in the ProSeal group as compared to the endotracheal group. CONCLUSIONS: The ProSeal LMA can be a better alternative to the endotracheal tube in neonates due to the ease of insertion, lesser changes in hemodynamic parameters and minimal postoperative complications.

Complications Encountered with ETV in Infants with Congenital Hydrocephalus.

BACKGROUND: Hydrocephalus is an abnormal excessive accumulation of cerebrospinal fluid (CSF) in the cavity and spaces of the brain. Endoscopic third ventriculostomy (ETV) has been an established treatment modality for congenital hydrocephalus. However, in very young infants, the results are challenging. In our study, we have evaluated whether ETV really offers an acceptable complication-free postoperative course. OBJECTIVE: To study the complication and mortality rate in infants having congenital hydrocephalus treated with ETV. MATERIALS AND METHODS: This is a single-center prospective study conducted at the Department of Neurosurgery, K. G. M. U, Lucknow, from January 2019 to February 2020. We studied 40 infants presenting with clinical and radiological features suggestive of congenital hydrocephalus. Follow-up was done at the first, third, and sixth months after discharge. RESULTS: Nineteen infants (47.5%) required a second CSF diversion procedure at 6 months of follow-up. The failure rate was significantly higher in infants less than 3 months of age (P value of 0.04). The ETV site bulge was the most frequent complication encountered in the postoperative period, occurring in 20% of the cases. Eventually, all these infants required a ventriculoperitoneal shunt; 15% developed clinical features consistent with the diagnosis of post-ETV meningitis. The ETV site CSF leak occurred in 10% of the patients. Subdural hygroma developed in 7.5% of the patients; 17.5% of the patients contributed to mortality with a mean time of expiry of 22 days post-procedure. All these deaths had multifactorial causes and could not be said as a complication or failure of ETV. CONCLUSION: We do not recommend ETV for infants less than 3 months because of a high failure rate. The ETV site bulge was the most reliable and earliest marker of failure and a second CSF diversion surgery should be immediately considered.

Usefulness of Thromboelastography for Perioperative Evaluation of Hemostatic Profile in Patients with Primary Brain Tumors Undergoing Surgery.

Context: Hemostatic abnormalities are more common in patients with brain tumors than systemic malignant diseases. Conventional coagulation tests (CCT) are poor assays for dynamic assessment of clot strength in whole blood. Thromboelastography (TEG) gives us detailed information on the dynamics of clot development, stabilization, and dissolution reflecting in vivo hemostasis. TEG can assess both thrombosis and fibrinolysis. Aims: This study aimed to investigate the temporal trends in hemostatic profile occurring during surgery for primary brain tumors, using a combination of TEG and CCT, and to assess perioperative blood component support. Subjects and Methods: A prospective, observational study was done on 40 patients with primary brain tumors larger than 4 cm in maximum diameter on computed tomography or magnetic resonance imaging. The tests (TEG and CCT [PT, INR, activated partial thromboplastin time, and platelet count]) were performed preoperatively (on the day of surgery), intraoperatively (2 h into surgery), and postoperatively (the day after surgery). Statistical Analysis: SPSS Version 21.0 statistical analysis software was used. Results: We found a universal trend toward hypercoagulability (persistent decrease in R-time, K-time and increase in MA, α-angle, Coagulation Index) in all the TEG parameters measured intraoperatively and postoperatively even though the values were within normal limits. Results of CCT had poor correlation with TEG parameters. The mean intraoperative blood loss was 737.7 ± 185.6 mL, for which PRBC was transfused in 17 patients, FFP in 13, but no platelet transfusion was done intraoperatively. Conclusions: We found a trend toward hypercoagulability in our study in intraoperative and postoperative period using TEG which was not evident on CCT. TEG was a useful diagnostic tool to identify coagulation abnormalities and to guide perioperative blood transfusion.

Effect of 4% nebulized lignocaine versus 2% nebulized lignocaine for awake fibroscopic nasotracheal intubation in maxillofacial surgeries.

INTRODUCTION: Securing a difficult airway during maxillofacial surgeries is a great challenge for anesthetists, and the flexible fiber-optic bronchoscope is the gold standard while managing such cases. While passing the flexible bronchoscope by the nasal route, the success rate is higher as compared with oral approach as the nasopharynx is in line with the larynx and prevents acute angulation in the oropharynx. MATERIALS AND METHODS: A randomized control trial was planned in 73 patients out of whom sixty patients gave consent for the procedure. The patients we randomly divided into two groups (n = 30) with application of 4% nebulized lignocaine in one group and the use of 2% nebulized lignocaine in the other group, and the patient's comfort was noted using five-point Puchner scale. RESULTS: The mean value of patient comfort Puchner scale of Group A was 1.30 ± 0.08 and of Group B was 2.23 ± 0.12. The mean value of Puchner scale of Group B was significantly higher (41.8%) as compared to Group A (t = 6.208; df = 51; P < 0.0001). The secondary outcome measures were optimal intubating conditions and hemodynamic changes during awake fiber-optic nasotracheal intubation. The procedural time of two groups when compared showed that the mean procedural time of Group A was shorter (29.67 ± 5.40 min) than the time consumed in Group B (34.93 ± 5.52 min). CONCLUSION: Four percent nebulized lidocaine provided adequate airway anesthesia and optimal intubating conditions along with stable hemodynamics for awake fiber-optic intubation as compared to 2% nebulized lidocaine.

Genetic polymorphism of interleukin-10 (-A592C) among oral cancer with squamous cell carcinoma.

OBJECTIVE: Interleukin-10 (IL-10) is a pleiotropic cytokine with either immunosuppressive or immunostimulative activities. It has been reported that in cancer, the promoter region polymorphism of IL-10 (-A592C) alters both the expression and serum levels of this cytokine. In the present study, we have addressed the question as to whether the single nucleotide polymorphisms (SNPs) at positions -592 A/C in the IL-10 gene promoter, could predispose an individual to oral squamous cell carcinoma (OSCC). DESIGN: We analyzed the genotype of the IL-10 (-A592C) gene, in 250 histopathologically confirmed OSCC patients and similar number of healthy volunteers taken as controls, in an Indian population by using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Allele and genotype frequencies were analyzed by the Student's t-test and the chi-squared test, and strength of associations by the odds ratio (OR) with 95% confidence intervals. RESULTS: The genotype and allele distribution of IL-10 (-A592C) gene polymorphism was significantly different between OSCC cases and controls (genotype AA vs AC: OR 2.87; 95 % CI 1.50-5.48; p=0.0016 and AA vs CC: OR 4.08; 95 % CI 1.98-8.41; p=0.0002). The -592 C alleles were found to be significantly different among OSCC cases and controls (OR: 1.44, 95% CI: 1.12-1.85, p<0.0051). CONCLUSIONS: The IL-10 gene promoter region (-592) A/C polymorphism is significantly associated with reduced risk of OSCC. The OSCC group had a significantly greater frequency of genotype AA as compared to control group.

Role of Thromboelastography Versus Coagulation Screen as a Safety Predictor in Pre-eclampsia/Eclampsia Patients Undergoing Lower-Segment Caesarean Section in Regional Anaesthesia.

PURPOSE: In this study, we aimed to correlate thromboelastography (TEG) variables versus conventional coagulation profile in all patients presenting with pre-eclampsia/eclampsia and to see whether TEG would be helpful for evaluating coagulation in parturients before regional anaesthesia. MATERIALS AND METHODS: This was a prospective study on 100 pre-eclampsia/eclampsia patients undergoing lower-segment caesarean section under regional anaesthesia. Two blood samples were collected. First sample was used for TEG measurement and second sample for laboratory tests. The following TEG data were obtained-reaction time, kinetic time, alpha angle, and maximum amplitude (MA). The following laboratory tests were obtained-haematology (haemoglobin, TLC, DLC, platelet count) and coagulation test [prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT)]. RESULT: Out of 100 patients enrolled in the study, 80 (80 %) had a normal coagulation profile, while remaining 20 (20 %) had hypocoagulation profile. The results show that TEG parameters have a good correlation with conventional coagulation profile and also showed excellent independent predictive efficacy for prediction of hypocoagulation. PT, aPTT, and TT were directly proportional to R-time and K-time and inversely proportional to alpha angle (p < 0.001). Platelet count showed a strong positive correlation with MA (p < 0.001). CONCLUSION: By giving a global picture of haemostasis, TEG can lead to improved decision-making about safety of using regional anaesthesia. Its fast feedback time makes it ideal for monitoring in a fast moving situation such as in obstetric emergency.

Multimodal versus Conventional Approach for Postoperative Pain Relief in Oral Cancer Patients.

INTRODUCTION: Multimodal analgesia includes regional anaesthesia in the form of nerve block may improve recovery along with optimal rehabilitation and early resumption of day-to-day activity following major surgery. Conventional general anaesthesia consists of premedication, induction, intubation and maintenance. AIM: The aim of the study is to compare the multimodal versus conventional approach in oral cancer surgery. MATERIALS AND METHODS: The patients were randomly allocated into three groups, 30 patients in each group using the computer generated random table to one of the following groups: Group A: Fentanyl 1 µg/kg, Group B: Fentanyl 1 µg/kg + bupivacaine local infiltration, Group C: Fentanyl 1 µg/kg + bupivacaine local infiltration + Dexemedetomidine infusion (Loading 0.5 µg/kg, Maintenance 0.2µg/kg/hr). RESULTS: No significant (p>0.05) difference was found in mean arterial pressure and heart rate at different time intervals among the groups. The VAS was lower in Group C than Group B and A. The ramsay sedation scale was higher in Group C than Group B and A. The rescue analgesic for 24 hour was lower in Group C than Group B and A. The time of first time analgesia requirement was significantly (p=0.001) higher in Group C than Group B and A. The rescue analgesic was significantly (p=0.001) lower in Group C (39.29±19.67) than Group B (68.33±18.49) and A (160.83±35.16). CONCLUSION: Multimodal analgesia has beneficial haemodynamic effects during oral cancer surgery with reliable postoperative analgesia and sedation and less postoperative complication. Dose of drugs used in our study is not associated with any major adverse effect.

PKCδ-IRAK1 axis regulates oxidized LDL-induced IL-1ß production in monocytes.

This study examined the role of interleukin (IL)-1 receptor-associated kinase (IRAK) and protein kinase C (PKC) in oxidized LDL (Ox-LDL)-induced monocyte IL-1ß production. In THP1 cells, Ox-LDL induced time-dependent secretory IL-1ß and IRAK1 activity; IRAK4, IRAK3, and CD36 protein expression; PKCδ-JNK1 phosphorylation; and AP-1 activation. IRAK1/4 siRNA and inhibitor (INH)-attenuated Ox-LDL induced secreted IL-1ß and pro-IL-1ß mRNA and pro-IL-1ß and mature IL-1ß protein expression, respectively. Diphenyleneiodonium chloride (NADPH oxidase INH) and N-acetylcysteine (free radical scavenger) attenuated Ox-LDL-induced reactive oxygen species generation, caspase-1 activity, and pro-IL-1ß and mature IL-1ß expression. Ox-LDL-induced secretory IL-1ß production was abrogated in the presence of JNK INH II, Tanshinone IIa, Ro-31-8220, Go6976, Rottlerin, and PKCδ siRNA. PKCδ siRNA attenuated the Ox-LDL-induced increase in IRAK1 kinase activity, JNK1 phosphorylation, and AP-1 activation. In THP1 macrophages, CD36, toll-like receptor (TLR)2, TLR4, TLR6, and PKCδ siRNA prevented Ox-LDL-induced PKCδ and IRAK1 activation and IL-1ß production. Enhanced Ox-LDL and IL-1ß in systemic inflammatory response syndrome (SIRS) patient plasma demonstrated positive correlation with each other and with disease severity scores. Ox-LDL-containing plasma induced PKCδ and IRAK1 phosphorylation and IL-1ß production in a CD36-, TLR2-, TLR4-, and TLR6-dependent manner in primary human monocytes. Results suggest involvement of CD36, TLR2, TLR4, TLR6, and the PKCδ-IRAK1-JNK1-AP-1 axis in Ox-LDL-induced IL-1ß production.

Tumor necrosis factor gene polymorphism results in high TNF level in sepsis and septic shock.

INTRODUCTION: Systemic sepsis releases several cytokines among which tumor necrosis factor alfa (TNFα) has emerged as key cytokine causing septic shock. Single Nucleotide Polymorphisms (SNPs) at positions -238, -308, -376 and +489 in the promoter region of TNF gene exhibit differential association to inflammation and increased TNF production in sepsis. MATERIALS AND METHODS: This research work was carried out in 278 critically ill patients and 115 controls. The patients were divided into four groups: Healthy controls, SIRS, Sepsis and Septic shock. Plasma cytokine level was evaluated by ELISA. Specific sequences of TNF gene (-238, -308, -376, +489) were amplified using polychromase chain reaction (PCR). SNP detected by BamHiI, NcoI, FokI, TaiI restriction enzymes. RESULTS: Mean plasma TNFα level in healthy Control group was 8.37 ± 2.23 pg/ml, in SIRS group, the mean plasma TNFα level was 77.99 ± 5.51 pg/ml, in Sepsis patients 187.1 ± 14.33 pg/ml and in septic shock 202.2 ± 14.85 pg/ml; range 56.17-417.1 pg/ml. SNP was studied among different patient groups, which showed a higher frequency of mutants among sepsis and shock patients as compared to control. CONCLUSION: Plasma TNF alpha level was significantly high in patients with sepsis and septic shock. SNP of TNF gene showed significant association between polymorphism and development of severe sepsis and septic shock, this would help us in evaluating patients at high risk for septic shock and such patients needed to obtain a rational basis for therapy.

Cytokines induced neutrophil extracellular traps formation: implication for the inflammatory disease condition.

Neutrophils (PMNs) and cytokines have a critical role to play in host defense and systemic inflammatory response syndrome (SIRS). Neutrophil extracellular traps (NETs) have been shown to extracellularly kill pathogens, and inflammatory potential of NETs has been shown. Microbial killing inside the phagosomes or by NETs is mediated by reactive oxygen and nitrogen species (ROS/RNS). The present study was undertaken to assess circulating NETs contents and frequency of NETs generation by isolated PMNs from SIRS patients. These patients displayed significant augmentation in the circulating myeloperoxidase (MPO) activity and DNA content, while PMA stimulated PMNs from these patients, generated more free radicals and NETs. Plasma obtained from SIRS patients, if added to the PMNs isolated from healthy subjects, enhanced NETs release and free radical formation. Expressions of inflammatory cytokines (IL-1ß, TNFα and IL-8) in the PMNs as well as their circulating levels were significantly augmented in SIRS subjects. Treatment of neutrophils from healthy subjects with TNFα, IL-1ß, or IL-8 enhanced free radicals generation and NETs formation, which was mediated through the activation of NADPH oxidase and MPO. Pre-incubation of plasma from SIRS with TNFα, IL-1ß, or IL-8 antibodies reduced the NETs release. Role of IL-1ß, TNFα and IL-8 thus seems to be involved in the enhanced release of NETs in SIRS subjects.

Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia.

BACKGROUND: Spinal anaesthesia is the most common approach which is used for lower limb surgery. Dexmedetomidine is the recent drug which acts on α2-adrenergic receptors in the dorsal horn of the spinal cord to produce analgesic effects. AIM: Efficacy and safety of intrathecal dexmedetomidine added to ropivacaine. SETTING AND DESIGN: Randomised double blind trial. METHODS: Sixty patients were randomly allocated to receive intrathecally either 3 ml of 0.75% isobaric ropivacaine + 0.5 ml normal saline (Group R) or 3 ml of 0.75% isobaric ropivacaine + 5 µg dexmedetomidine in 0.5 ml of normal saline (Group D). RESULTS: The mean time of sensory regression to S2 was 468.3±36.78 minutes in group D and 239.33±16.8 minutes in group R. Duration of analgesia (time to requirement of first rescue analgesic) was significantly prolonged in group D (478.4±20.9 minutes) as compared to group R (241.67±21.67 minutes). The maximum visual analogue scale score for pain was less in group D (4.4±1.4) as compared to group R (6.8±2.2). CONCLUSION: The addition of dexmedetomidine to ropivacaine intrathecally produces a prolongation in the duration of the motor and sensory block.

A Comparative study of intrathecal dexmedetomidine and fentanyl as adjuvants to Bupivacaine.

BACKGROUND: Various adjuvants have been used with local anesthetics in spinal anesthesia to avoid intraoperative visceral and somatic pain and to provide prolonged postoperative analgesia. Dexmedetomidine, the new highly selective α2-agonist drug, is now being used as a neuraxial adjuvant. The aim of this study was to evaluate the onset and duration of sensory and motor block, hemodynamic effect, postoperative analgesia, and adverse effects of dexmedetomidine or fentanyl given intrathecally with hyperbaric 0.5% bupivacaine. MATERIALS AND METHODS: Sixty patients classified in American Society of Anesthesiologists classes I and II scheduled for lower abdominal surgeries were studied. Patients were randomly allocated to receive either 12.5 mg hyperbaric bupivacaine plus 5 µg dexmedetomidine (group D, n = 30) or 12.5 mg hyperbaric bupivacaine plus 25 µg fentanyl (group F, n = 30) intrathecal. RESULTS: Patients in dexmedetomidine group (D) had a significantly longer sensory and motor block time than patients in fentanyl group (F). The mean time of sensory regression to S1 was 476±23 min in group D and 187±12 min in group F (P<0.001). The regression time of motor block to reach modified Bromage 0 was 421±21 min in group D and 149±18 min in group F (P<0.001). CONCLUSIONS: Intrathecal dexmedetomidine is associated with prolonged motor and sensory block, hemodynamic stability, and reduced demand for rescue analgesics in 24 h as compared to fentanyl.

Optimization of subarachanoid block by oral pregabalin for hysterectomy.

BACKGROUND: 80% of patients undergoing surgical procedures experience postoperative pain1 and requires adequate pain relief. Nowadays drugs like COX2 inhibitors and calcium channel modulators (Pregabalin and Gabapentin) are been increasingly used for postoperative pain management effectively. We conducted this study to find whether preoperative pregabalin has any effect in postoperative analgesic requirement in patients undergoing hysterectomy under spinal anaesthesia. PATIENTS #ENTITYSTARTX00026; METHODS: This randomized, double-blind, placebo-controlled trial was conducted in 150 patients undergoing hysterectomy under spinal anaesthesia, divided in three groups - Group I (PO) - Control group, Group II (P150) received 150 mg pregabalin and Group III (P300) received 300 mg pregabalin. We used VAS for anxiety, Ramsay sedation scale and VAS for patient satisfaction regarding pain relief. RESULTS: There was significant reduction in anxiety in groups P (150) and P (300) than placebo group P (0) during intraoperative and postoperative period than preoperative period. There was significant sedation seen in groups P (150) and P (300) than placebo group P (0). First rescue analgesia in group P (300) was202.42±6.77 and in group P (150) was176.38±4.80on average, group P (0) was131.38±5.15. Dizziness was 44.44% in group P (300), 36.11% in group P (150), and 19.44% in group P (0). Patient satisfaction was better in P (300) group than other two groups. CONCLUSIONS: Pregabalin being an oral drug which would be easy for the patients to take and also its prolongation of the neuraxial block helps in immediate postoperative analgesia and further reduction of other parentral analgesics. Pregabalin 150mg would be the optimal preemptive dose for hysterectomy under spinal anaesthesia.