Efficacy of analgesia using ilioinguinal-iliohypogastric (IIIH) nerve block, transversus abdominis plane (TAP) block and diclofenac after caesarean delivery under spinal anaesthesia: A non-randomised clinical trial.

Background and Aims: Our aim was to assess the efficacy of analgesia using ilioinguinal-iliohypogastric (IIIH) nerve block, transversus abdominis plane (TAP) block and diclofenac after caesarean delivery (CD) under spinal anaesthesia (SA).]. Methods: A total of 457 healthy parturients undergoing CD under SA were included in this prospective, observational study. Groups differed in the postoperative analgesic strategies received by the parturient at the end of surgery: group D (n = 148) received intramuscular diclofenac sodium, group I (n = 153) received bilateral IIIH block with bupivacaine plus clonidine and group T (n = 156) received bilateral TAP block with bupivacaine plus clonidine. Total duration of postoperative analgesia, numerical pain rating scale (NRS) scores, patient satisfaction score, rescue analgesics in the first 48 h postoperatively and adverse effects were observed. A value of P < 0.05 was taken as significant. Results: Total duration of analgesia was longest (18.2 ± 1.3 h) in group T and shortest in group D (6.3 ± 0.8 h) compared to group I (13.1 ± 1.2 h) (P < 0.001). Total analgesic requirement in postoperative 48 h was lowest in group T (152.1 ± 34.9 mg), highest in group D (355.0 ± 25.6 mg) and intermediate in group I (221.0 ± 30.0 mg) (P < 0.001). Mean NRS scores were lower in group T compared to those in groups D and I. The patients in group T were extremely satisfied, in group I were satisfied and in group D were dissatisfied (P < 0.001). Conclusion: Bilateral TAP block with bupivacaine and clonidine after CD under SA increases the duration of postoperative analgesia.

Recent advances in anaesthesia for intrauterine and foetal surgery.

Advances in prenatal diagnostic techniques have enabled early detection of potentially correctable foetal anomalies. Here, we summarise recent developments in anaesthesia for foetal surgery. Types of foetal surgery include minimally invasive, open mid-gestational and ex-utero intrapartum treatment (EXIT) procedures. Foetoscopic surgery avoids hysterotomy, with risk of uterine dehiscence, preserving the possibility of subsequent vaginal delivery. Minimally invasive procedures are performed under local or regional anaesthesia; open or EXIT procedures are usually done under general anaesthesia. Requirements include maintenance of uteroplacental blood flow, and uterine relaxation to prevent placental separation and premature labour. Foetal requirements include monitoring of well-being, providing analgesia and immobility. EXIT procedures require maintenance of placental circulation till the airway is secured, requiring multidisciplinary involvement. Here, the uterine tone must return after baby delivery to prevent major maternal haemorrhage. The anaesthesiologist plays a crucial role in maintaining maternal and foetal homeostasis and optimising surgical conditions.

Perioperative Course of COVID-19 in Pediatric Patients Undergoing Emergency Surgeries.

Objective: Adults with COVID-19 infection undergoing surgery have an increased risk of complications and mortality. However, literature mentioning the perioperative course and outcome of children with COVID-19 infection undergoing emergency surgery is still lacking. Therefore, we planned this study to observe the need for postoperative ventilation, oxygen requirements, and postoperative mortality in pediatric patients with COVID-19 infection scheduled for emergency surgery. Methods: After ethical committee approval, all the COVID-19-infected pediatric patients who underwent an emergency surgery from April 2020 to May 2021 were included. Data collected included details of COVID-19 disease, American Society of Anesthesiology (ASA) grading, comorbidities, perioperative details such as tachycardia or bradycardia, any oxygen desaturation (SpO2<90), need for postoperative oxygen therapy, postoperative ventilation, and recovery/death. Results: A total of 22 COVID-19-infected pediatric patients underwent emergency surgery in the study period. Fourteen (63.6%) were asymptomatic at the time of admission. Nineteen patients (86.4%) belonged to ASA grade IE and three (13.6%) patients belonged to ASA grade III E. Three patients (13.6%) had comorbidities. Only one patient had hypotension and tachycardia intraoperatively. The same patient needed postoperative ventilation and succumbed. Conclusion: Our study shows that pediatric surgical patients with COVID-19 infection do not exhibit an increased need for oxygen or postoperative ventilation, postoperative pulmonary complications, or high mortality unless there is associated comorbidity.

An observational study to evaluate the effect of different epidural analgesia regimens on dynamic pain scores in patients receiving epidural analgesia for postoperative pain relief after elective gynecological surgery.

BACKGROUND AND AIMS: The primary measure of efficacy of any analgesic regimen is pain relief, but it is important to measure dynamic pain relief rather than pain relief at rest. Epidural analgesia is an effective technique for postoperative analgesia. The drug combinations given therein (local anesthetics with adjuvants such as opioids/alpha-2 agonists), however, remain a personal choice. The aim of this study was to evaluate dynamic pain scores in patients receiving different epidural analgesia regimens for postoperative pain relief after elective gynecological surgery used in our institution. MATERIAL AND METHODS: One hundred eighty-seven patients enrolled in this study received postoperatively either bupivacaine 0.125% + morphine 0.1 mg/mL (group BM) or bupivacaine 0.125% + fentanyl 2 µg/mL (group BF) or bupivacaine 0.125% + clonidine 1 µg/mL (group C1) or bupivacaine 0.125% + clonidine 2 µg/mL (group C2) by continuous epidural infusion @ 5 mL/h. Differences in dynamic pain scores (on coughing and mobilization), pain scores at rest, sensory and motor blockade, sedation scores, dry mouth, pruritus, nausea, and vomiting were recorded. Also duration of postoperative analgesia, epidural top-ups, requirement of rescue analgesic, and patient satisfaction were determined. All observations were carried out at 1, 2, 4, 8, and 12 h after surgery and then at 8 am, 12 noon, 4 pm, 8 pm on subsequent postoperative day till removal of epidural catheter (after 96 h). RESULTS: There was no difference in demographic or hemodynamic profile among the four groups (P > 0.05). There was no statistically significant difference in pain scores at rest among the four groups but dynamic pain scores were found to be better in group C2 as compared to group BM, BF, and C1 at most of the time intervals although not statistically significant (P > 0.05). Requirement of rescue analgesics was lower in group BM and group C2 as compared to group BF and C1 (P < 0.01). Incidence of pruritus was 43.5% in group BM and 19% in group BF, while no patients in group C1 or C2 had pruritus. Mean postoperative nausea and vomiting (PONV) scores were higher in group BM and group BF as compared to group C1 and C2 (P < 0.001). Mean sedation scores were comparable in all four groups. Incidence of dry mouth was 22% in group C2 as compared to 11% in group C1, while no patients in group BM or BF had dry mouth. Patients in group C2 were more satisfied as compared to other three groups. CONCLUSIONS: Combination of clonidine 2 µg/mL to 0.125% bupivacaine @ 5 mL/h in combined spinal epidural provides better postoperative analgesia as compared to combination of bupivacaine with opioids with greater patient satisfaction and significantly reduced side effects.

A randomised trial to compare Truview PCD®, C-MAC® and Macintosh laryngoscopes in paediatric airway management.

AIM: To evaluate and compare the Truview PCD and C-MAC laryngoscopes to the standard Macintosh laryngoscope in paediatric patients. METHODS: One hundred and fifty ASA I-II patients in the age group of 1-6 years (10-20 kg) scheduled for elective surgery were randomised into three equal groups for laryngoscopy and intubation with either Truview PCD (Group T), C-MAC (Group C) or Macintosh (Group M) laryngoscopes under general anaesthesia. Percentage of glottic opening (POGO) score, application of external laryngeal manoeuvre, time to intubation, number of attempts at intubation, failed intubations, episodes of desaturation and trauma caused were recorded and statistically analysed. A p value of <0.05 was taken as significant. RESULTS: POGO scores were significantly better with Truview PCD as compared with C-MAC and Macintosh laryngoscopes (94.7 ± 12.9/82 ± 25.0/85.1 ± 17.1; p < 0.01). There were no failed attempts, episodes of desaturation or trauma in any of the patients. The mean intubation time taken was 19.2 s in group T, 12.3 s in group C and 10.7 s in group M, respectively. There is a statistically significant difference among groups (p < 0.01). Eight patients in group T, 21 out of 50 patients in group C and 19 out of 50 patients in group M needed OELM, respectively. There is significant difference among the groups (p < 0.01) CONCLUSION: Using Truview PCD to assist intubation offers excellent view field of glottic opening after OLEM and the mean time taken is less than 20 s. The Truview PCD tool is suitable for paediatric patients.

WITHDRAWN: A randomized trial to compare the Truview picture capture device, C-MAC laryngoscope, and Macintosh laryngoscope in pediatric airway management.

AIM: To evaluate and compare the Truview picture capture device (PCD) and C-MAC laryngoscope to the standard Macintosh laryngoscope in pediatric patients. METHODS: One hundred and fifty patients with American Society of Anesthesiology status Grade I-II (ASA I-II) who were 1-6 years old (10-20 kg) were scheduled for elective surgery. They were randomized into three equal groups for laryngoscopy and intubation by either the Truview PCD (Group T), C-MAC (Group C), or Macintosh laryngoscope (Group M) under general anesthesia. The percentage of glottic opening (POGO) score, application of external laryngeal maneuver, time to intubation, number of attempts at intubation, failed intubations, episodes of desaturation, and trauma were recorded and statistically analyzed. A value of p < 0.05 was considered significant. RESULTS: The POGO scores were significantly better with the Truview PCD (94.7 ± 12.91) than with the C-MAC and Macintosh laryngoscopes (82 ± 24.97 and 85.1 ± 17.07, respectively; p < 0.01). There were no failures, episodes of desaturation, or trauma in any of the patients. It took 19.24 seconds to intubate with the Truview PCD, compared to 12.32 seconds with the C-MAC laryngoscope and 10.7 seconds with the Macintosh laryngoscope (p < 0.01). An external laryngeal maneuver was required in 42% of patients in group C, compared to 38% in Group M and 16% in group T (p < 0.01). CONCLUSION: The Truview PCD offers the best laryngeal view, although it takes a longer time for intubation. The C-MAC laryngoscope provides similar laryngeal views as the Macintosh blade, and is an excellent teaching aid.

A case series study of therapeutic implications of type IIIb4: a rare variant of esophageal atresia and distal tracheoesophageal fistula.

BACKGROUND: A wide spectrum of variations can occur in type IIIb esophageal atresia and distal tracheoesophageal fistula [EA-TEF] (Kluth D. Atlas of esophageal atresia. J Pediatr Surg 1976; 11 (6):901-19). The aim of this study was to evaluate the variant anatomy of subtype IIIb4 EA-TEF and its therapeutic implications. METHODS: We performed a retrospective review of 4 patients of this variant subtype within a series of 259 esophageal atresias, managed over a study period of three years, at our institution. The diagnosis was made at thoracotomy. The overlapping upper and lower esophageal pouches, initially, gave a false impression of esophageal continuity. The long TEF coursed parallel in proximity to the upper pouch (UP) and the trachea needing meticulous dissection. The TEF measured 8-10mm in diameter and was ligated and divided high on the trachea near the thoracic inlet. The patients were followed up by a contrast swallow, radioactive technetium-99m- sulfur colloid scan, echocardiography and bronchoscopy (if indicated). RESULTS: The mean birth weight and gestational age was 2250 g and 38 weeks respectively. The mean follow up was eighteen months (range 5-42 months). An associated anorectal malformation was present in two patients while none had associated congenital heart disease. The Waterston grading was A and B in one patient each and C in two patients. All the patients had muscular UP extending up-to the level of arch of azygous vein (T(3-4)). The lower esophageal pouch (LP) and the fistula extended high, near the thoracic inlet. Tracheal injury occurred in one patient, with thin LP, warranting postoperative elective ventilation. A postoperative barium swallow did not reveal anastomotic leak or stricture in any patient. Follow-up barium swallow showed long LP extending high up in the chest, up to clavicles in all four patients and redundancy of UP in case 1. Severe gastroesophageal reflux was present in two patients. Bronchoscopy revealed tracheomalacia in case 1. Three patients were thriving well at the last follow-up. One patient died at five months of age due to aspiration pneumonia. CONCLUSIONS: The knowledge of diagnostic and therapeutic implications of the variant subtype IIIb4 EA-TEF should be in the armamentarium of the treating surgeon to reduce pitfalls in its management.

Fetal hydantoin syndrome and its anaesthetic implications: a case report.

Fetal hydantoin syndrome is a rare disorder that is believed to be caused by exposure of a fetus to the anticonvulsant drug phenytoin. The classic features of fetal hydantoin syndrome include craniofacial anomalies, prenatal and postnatal growth deficiencies, underdeveloped nails of the fingers and toes, and mental retardation. Less frequently observed anomalies include cleft lip and palate, microcephaly, ocular defects, cardiovascular anomalies, hypospadias, umbilical and inguinal hernias, and significant developmental delays. Anaesthesia for incidental surgery in such a patient poses unique challenges for the anesthesiologist. We report the successful management of a 4-year-old male child with fetal hydantoin syndrome, cleft palate, spina bifida, atrial septal defect, and dextrocardia for tibialis anterior lengthening under subarachnoid block.

A comparison of Truview infant EVO2 laryngoscope with the Miller blade in neonates and infants.

BACKGROUND: The Truview EVO2 laryngoscope is a recently introduced device with a unique blade that provides a wide and magnified laryngeal view at 46 degrees anterior refracted angle. An infant blade of the laryngoscope has recently become available. AIMS AND OBJECTIVES: The aim of the study was to compare the Truview infant EVO2 laryngoscope with the Miller straight blade laryngoscope in order to determine whether the Truview EVO2 laryngoscope provided an improved laryngeal view at laryngoscopy and also to assess the time taken for intubation with the two devices. MATERIALS AND METHODS: In this prospective randomized study, 60 neonates and infants of either sex undergoing surgery under general anesthesia were enrolled and divided into two groups: endotracheal intubation using a Truview infant blade (Group I) or with a Miller blade number 0 (Group II). The view of the glottis at laryngoscopy, time to intubation and the number of attempts required for intubation were recorded. RESULTS: The average time for laryngoscopy in Group I was 18.18 s and in Group II was 16.30 s, which though not significant clinically, is statistically significant (P = 0.002). While eight patients (26.6%) had Cormack and Lehane grade 2 view on laryngoscopy in Group II, only two patients (6.6%) had such a view in Group 1 (P = 0.039). The number of attempts at laryngoscopy was comparable in the two groups. CONCLUSION: In this study, we found that in neonates and infants, the tracheal intubation using Truview infant EVO2 blade took almost as much time as miller blade and provided improved laryngoscopic view as compared to the Miller blade.

Infliximab treatment in a patient with rheumatoid arthritis on hemodialysis.

We describe a 60-year-old woman with active rheumatoid arthritis (RA) and endstage renal disease secondary to hypertensive nephrosclerosis undergoing hemodialysis. She had tried multiple antirheumatic medications; however, their usefulness was limited due to toxic side effects or lack of efficacy. She was then treated with chimeric antitumor necrosis factor monoclonal antibody (infliximab), which resulted in immediate improvement in clinical and laboratory measures. After about 2 years of therapy, no side effects have been observed. This report expands the spectrum of infliximab to include RA patients with renal insufficiency.