Ultrasound-guided adductor canal block versus femoral nerve block for arthroscopic anterior cruciate ligament repair under general anesthesia.

BACKGROUND AND AIMS: Adductor canal block (ACB) is now an established component of multimodal analgesia for knee replacement surgery and is slowly replacing femoral nerve block (FNB). It is also gaining popularity for providing pain relief in knee arthroscopies including anterior cruciate ligament reconstruction surgery (ACLR). Data is lacking from the Indian subcontinent on comparing ACB to the traditional FNB for ACLR. Hence, we conducted the present study to compare ACB and FNB in ACLR under general anesthesia. MATERIAL AND METHODS: Sixty patients were randomized to receive either ACB or FNB under ultrasound guidance. Postoperatively, quadriceps muscle strength (straight leg raise and time up and go; TUG test) and quality of analgesia (numeric rating scale; NRS and patient satisfaction score) were assessed every 6 hour, and thereafter, up to 48 hours. The time of rescue analgesia and total analgesic consumption (tramadol) were also recorded. Data was statistically analyzed and P < 0.05 was considered to be significant. RESULTS: Patients receiving ACB had significantly less quadriceps weakness (P < 0.001) compared to FNB on postoperative day (POD) 1. In addition, patient satisfaction score was statistically higher (P < 0.05) in FNB on POD1. Both the above parameters were comparable on POD2. No statistically significant difference was recorded in NRS, time for rescue analgesia, and total analgesic consumption among the two groups. CONCLUSION: ACB preserves quadriceps motor strength while providing analgesia comparable to FNB in patients undergoing ACLR. However, patient satisfaction score is better with FNB than ACB.

Incidence of hemidiaphragmatic paresis after peripheral nerve stimulator versus ultrasound guided interscalene brachial plexus block.

BACKGROUND AND AIMS: We compared interscalene brachial plexus block (ISBPB) using peripheral nerve stimulation (PNS) and ultrasound (US) techniques. The primary outcomes were the incidence of hemidiaphragmatic paresis (HDP) and the duration of the block. Secondary outcomes were the block success rate, time to conduct the block, onset of sensory block, and dermatomal spread, postoperative pain by Numeric Rating Scale (NRS), duration of postoperative analgesia and incidence of complications. MATERIAL AND METHODS: We conducted a prospective, randomized, and observer-blinded study in 60 patients undergoing shoulder arthroscopy under block plus general anesthesia. ISBPB was performed with 10 ml of 0.5% bupivacaine using either PNS (Group PNS, n = 30) or US (Group US, n = 30). Hemidiaphragmatic function, the primary outcome, was assessed by ultrasonographic evaluation of diaphragmatic movement and pulmonary function tests using a bedside spirometer (forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate). General anesthesia was administered to all the patients for surgery. P < 0.05 test was considered to be statistically significant. RESULTS: Twelve patients in Group PNS had HDP and none in Group US (P < 0.0001). PFTs were also significantly reduced in Group PNS (P < 0.0001). The time to conduct the block and sensory onset time both were less in Group US (P < 0.05). The groups did not differ in block success rate, duration of analgesia, and NRS. Other complications like incidence of Horner's syndrome and vascular puncture were comparable in both the groups. CONCLUSIONS: PNS guided ISBPB with 10 ml of 0.5% bupivacaine is associated with a higher incidence of HDP as compared to US guided ISBPB. There is no significant difference in quality or duration of analgesia in the two groups.

Evolution of anaesthesia technique for endolaryngeal surgery through and post-COVID-19 pandemic: An experience from a tertiary referral centre for airway surgery.

Background and Aims: Anaesthesia for endolaryngeal surgery is specialised to provide almost a tubeless surgical field. During the coronavirus disease-19 pandemic, when most of the surgeries were staggered, we being in a tertiary referral centre for airway surgery had to modify our existing techniques and observed an evolution in the anaesthesia management which we could continue even in the postpandemic period. Hence, we conducted this retrospective study to analyse the reliability of our locally developed apnoeic high-flow oxygenation technique (AHFO) for endolaryngeal procedures. Methods: We conducted this single-centric retrospective study from January 2020 to August 2021 to observe the choice of airway management techniques in endolaryngeal surgery and assess the feasibility and safety of AHFO. We also intend to propose an algorithm for airway management. We calculated the percentages of all necessary parameters to denote the trend in change of practices roughly classifying the study period as prepandemic, pandemic and postpandemic. Results: A total of 413 patients were analysed in our study. The changing trend over preference of AHFO from prepandemic (72%) and dominance of AHFO (92.5%) in the postpandemic period are the most significant observations of our study with 17% patients needing conversion to tube in-tube out technique due to desaturation which is comparable to 14% in prepandemic period. Conclusion: The tubeless field provided by AHFO replaced the conventional airway management techniques. Our study demonstrates the safety and feasibility of AHFO for endolaryngeal surgeries. We also propose an algorithm for anaesthetists involved in laryngology unit.

Anaesthetic management of robot-assisted laparoscopic surgery.

Recent trend shows that minimally invasive surgery is in great demand. Robot-assisted procedures have become more popular, as they overcome several drawbacks of traditional laparoscopic techniques. Robotic surgery, however, might necessitate changes in how patients are positioned and how staff and equipment are organised generally, which might go against the traditional approach to anaesthesia care. The novel effects of this technology have the potential to produce paradigm-shifting therapeutic improvements. To provide better anaesthetic treatment and advance patient safety, anaesthesiologists should be aware of these developments by understanding the fundamental components of robotic surgical systems.

To Study the Efficacy of Intravenous Dexamethasone in Prolonging the Duration of Spinal Anesthesia in Elective Cesarean Section.

BACKGROUND AND AIMS: Various additives have been evaluated for the purpose of enhancing quality of analgesia and prolonging duration of spinal anesthesia. This randomized, double-blind study was conducted to evaluate the efficacy of intravenous dexamethasone in spinal anesthesia. METHODS: A total of sixty patients scheduled for lower segment cesarean section under spinal anesthesia were randomly allocated into two groups, group SD and group SN, including thirty patients each. All the patients received injection bupivacaine 0.5% heavy 10 mg through spinal anesthesia. Group SD received injection dexamethasone 8 mg intravenously, and group SN received injection normal saline (NS) 2 cc immediately after spinal anesthesia. Duration of sensory block, motor block, postoperative analgesia, visual analog pain scale (VAS) score, time of rescue analgesia, total analgesic requirement in the first 24 h, intra- and post-operative hemodynamics, and side effects if any were recorded. Whenever demanded rescue analgesia was given in the form of injection tramadol 100 mg. RESULTS: The mean duration of sensory block (min) in group SD and group SN was 162.50 and 106.17, respectively which was highly significant. Similarly, time to the requirement of first rescue analgesia was prolonged in group SD (8.67 h) as compared to group SN (4.40 h). Significant changes were also seen in VAS score in postoperative period after 1 h of surgery in group SD and group SN. Duration of motor block, intra- and post-operative hemodynamic parameters were comparable in both the groups. No side effects were recorded in both the groups. CONCLUSION: We concluded that administration of dexamethasone 8 mg intravenously prolongs the duration of postoperative analgesia and sensory block in patients undergoing lower segment cesarean section under spinal anesthesia.

The Analgesic Efficacy of Dexamethasone Added to Ropivacaine in Transversus Abdominis Plane Block for Transabdominal Hysterectomy under Subarachnoid Block.

BACKGROUND AND AIMS: Ultrasound-guided transversus abdominis plane (TAP) block has been proven as a safe and effective analgesic technique for several lower abdominal surgeries. Various adjuvants have been used to intensify the quality and prolong the local anesthetic effect. We evaluated the analgesic efficacy of dexamethasone addition to ropivacaine in TAP block following open abdominal hysterectomy. MATERIALS AND METHODS: After clearance from the Institutional Ethics Committee, a double-blind, prospective, randomized study was carried out on sixty patients aged 40-60 years posted for elective open abdominal hysterectomy comparing bilateral TAP block using 20 ml of 0.5% ropivacaine + 1 ml of 0.9% saline (control Group R) or 20 ml of 0.5% ropivacaine + 4 mg dexamethasone (Group RD). The aim of our study was to observe postoperative pain score (visual analog scale [VAS]), time for first analgesic (TFA) demand, total analgesic consumption, and incidence of nausea or vomiting. STATISTICAL ANALYSIS: Chi-square test and Student's t-test were used, and P < 0.05 was considered as statistically significant. RESULTS: Postoperative VAS pain scores were significantly lower at 4, 6, and 12 h in Group RD as compared to Group R (P < 0.05). Significantly longer TFA (13.2 ± 7.6 vs. 7.1 ± 4.6 h, P < 0.001) with lesser tramadol requirement in first 24 h (50.2 ± 34 vs. 94 ± 35 mg, P < 0.001) were observed in Group RD as compared to Group R. Incidence of nausea or vomiting was statistically insignificant between the groups (P > 0.05). CONCLUSIONS: Addition of dexamethasone to ropivacaine TAP block prolonged the postoperative analgesia and reduced analgesic requirement following abdominal hysterectomy.

Ultrasound-guided transversus abdominis plane block for post-operative analgesia in patients undergoing caesarean section.

BACKGROUND AND AIMS: Transversus abdominis plane (TAP) block is a fascial plane block providing post-operative analgesia in patients undergoing surgery with infra-umbilical incisions. We evaluated analgesic efficacy of TAP block with ropivacaine for 24 h after caesarean section through a Pfannenstiel incision. METHODS: Sixty patients undergoing caesarean section under spinal anaesthesia were randomised to undergo TAP block with ropivacaine (n = 30) versus control group (n = 30) with normal saline, in addition to standard analgesia with intravenous paracetamol and tramadol. At the end of the surgery, ultrasound-guided TAP plane block was given bilaterally using ropivacaine or normal saline (15 ml on either side). Each patient was assessed post-operatively by a blinded investigator at regular intervals up to 24 h for visual analogue score (VAS) and requirement of analgesia. SPSS version 18.0 software was used. Demographic data were analysed using Student's t-test and the other parameters using paired t-test. RESULTS: TAP block with ropivacaine compared with normal saline reduced post-operative VAS at 24 h (P = 0.004918). Time for rescue analgesia in the study group was prolonged from 4.1 to 9.53 h (P = 0.01631). Mean requirement of tramadol in the first 24 h was reduced in the study group. CONCLUSION: US guided TAP block after caesarean section reduces the analgesic requirement in the first 24 h.

Combined spinal and general anesthesia is better than general anesthesia alone for laparoscopic hysterectomy.

CONTEXT: Spinal anesthesia (SA) was combined with general anesthesia (GA) for achieving hemodynamic stability in laparoscopic hysterectomy. AIMS: The aim of our study was to evaluate the impact of SA combined with GA in maintaining hemodynamic stability in laparoscopic hysterectomy. The secondary outcomes studied were requirement of inhaled anesthetics, vasodilators, and recovery profile. SETTINGS AND DESIGN: We conducted a prospective, randomized study in ASAI/II patients posted for laparoscopic hysterectomy, who were willing to participate in the study. MATERIALS AND METHODS: Patients were randomly assigned to receive SA with GA (group SGA) or plain GA (group GA). Group SGA received 10 mg bupivacaine (heavy) for SA. GA was administered using conventional balanced technique. Maintenance was carried out with nitrous oxide, oxygen, and isoflurane. Comparison of hemodynamic parameters was carried out during creation of pneumoperitoneum and thereafter. Total isoflurane requirement, need of vasodilators, recovery profile, and regression of SA were studied. STATISTICAL ANALYSIS USED: Descriptive statistics in the form of mean, standard deviation, frequency, and percentages were calculated for interval and categorical variables, respectively. One-way analysis of variance (ANOVA) was applied for noting significant difference between the two groups, with chi-square tests for categorical variables and post-hoc Bonferroni test for interval variables. Comparison of heart rate (HR), mean arterial pressure (MAP), SPO2, and etCO2 was done with Student's t-test or Mann-Whitney test, wherever applicable. RESULTS: Patients in group SGA maintained stable and acceptable MAP values throughout pneumoperitoneum. The difference as compared to group GA was statistically significant (P < 0.01). Group GA showed additional requirement of metoprolol (53.33%) and higher concentration of isoflurane (P < 0.001) to combat the increased MAP. Recovery was early and quick in group SGA as against group GA (P = 0.000). There were no adverse/residual effects of SA. CONCLUSION: The hemodynamic repercussions during pneumoperitoneum can be effectively attenuated by combining SA and GA, without any adverse effects.

Twin pregnancy with HELLP syndrome complicated with acute renal failure for emergency cesarean section: An unusual case and its anesthetic management.

Acute renal failure is not common in pregnancy. However, the incidence rises when pregnancy is complicated with Hemolysis, Elevated Liver enzymes, Low Platelets (HELLP) syndrome, which itself is a rare occurrence. We had an unusual case of HELLP syndrome in twin pregnancy with deranged renal profile for emergency cesarean section. We report the case, its anesthetic management for emergency cesarean section, and perioperative supportive treatment for acute renal failure.

Dexmedetomidine as an anesthetic adjuvant in laparoscopic surgery: An observational study using entropy monitoring.

BACKGROUND: Dexmedetomidine is a highly selective α(2) agonist with properties of sedation, analgesia and anxiolysis, making it an ideal anesthetic adjuvant. Using an anesthetic adjuvant that decreases requirement of anesthetics and analgesics may predispose the patient to awareness. We monitored the depth of anesthesia (DOA) using entropy to avoid unwanted awareness under anesthesia. MATERIALS AND METHODS: 30 patients, American Society of Anesthesiologists grade I and II, aged between 18 to 50 years of either gender undergoing laparoscopic surgeries under general anesthesia were studied. Loading dose infusion of dexmedetomidine was started 1 mcg/kg for 15 minutes and patients were premedicated. Routine induction with propofol and fentanyl was carried out, and maintenance infusion of dexmedetomidine 0.2 mcg/kg/hr was given. Patients were monitored with standard monitoring, and in addition, the DOA was monitored with entropy. RESULTS: A 62.5% reduction (0.75 mg/kg) in the induction dose of propofol was observed, with a 30% less end-tidal concentration of isoflurane requirement for maintenance of anesthesia, while maintaining the adequate DOA. CONCLUSION: Dexmedetomidine is an effective anesthetic adjuvant that can be safely used in laparoscopy without the fear of awareness under anesthesia.

A very rare case of Cushing's disease for cesarean section: What the anesthesiololgist needs to know.

Cushing's syndrome is uncommon in pregnancy, and Cushing's disease being the cause for this syndrome is still rare. We had the opportunity to manage such a patient admitted for cesarean section. Here, we describe the evaluation of a patient with Cushing's syndrome in pregnancy along with its anesthetic implications. By describing this case, we intend to emphasize the role of the anaesthesiologist as a peri operative physician.

Evaluation of the effect of intrathecal clonidine to decrease shoulder tip pain in laparoscopy under spinal anaesthesia.

Sixty ASA grade I/II patients scheduled for elective short laparoscopic procedures under spinal anaesthesia were divided into two groups of 30 each. The first group (group C) received 3.5 ml of hyperbaric bupivacaine with 30 mcg of clonidine. The second group (group B) received plain bupivacaine 3.5 ml. Till date, the limiting factor for use of spinal anaesthesia for laparoscopy was patient's discomfort due to shoulder tip pain. From our study it can be concluded that bupivacaine along with clonidine in low doses provides good sedation and analgesia in intraoperative and post-operative period and at the same time abolishes shoulder tip pain during laparoscopic procedures. In addition, no significant changes in haemodynamics occur with the low dose of clonidine used.