Validity of P-POSSUM in adult cancer surgery (PACS).

Background and Aims: Objective prediction of postoperative morbidity and mortality can help clinicians for appropriate resource allocation and counseling of patients and their kin. Among different scoring systems, "Portsmouth- Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity" (P-POSSUM) includes both preoperative and intraoperative parameters for postoperative risk prediction. The aim of this study was to investigate the validity of morbidity prediction by P-POSSUM in patients requiring intensive care after undergoing major surgeries for gastrointestinal and gynecological malignancies. Material and Methods: All adult patients (>18 years) undergoing gastrointestinal and gynecological cancer surgeries who were shifted to intensive care unit (ICU) or high dependency unit (HDU) for postoperative care were included and P-POSSUM was measured. Postoperative complications were graded as per Clavien-Dindo (CD) grading and have been compared with predicted complications as per P-POSSUM. Results: 143 patients were included in the study and the median P-POSSUM score was 35. The mean predicted morbidity was 55.28% (SD 25.54%) and the observed complications were 45.45%, which shows P- POSSUM has over predicted morbidity. At P-POSSUM values 60 and above, the incidence of major complications was 22.22%, compared to 6.25% for the rest (Odds ratio 4.286). Conclusion: P-POSSUM is not a reliable predictor of postoperative morbidity for patients undergoing major gynecological and gastrointestinal surgeries for cancer in our institution. But there is a significant incidence of major complications with P- POSSUM morbidity prediction score 60 or higher leading to the need for more stringent assessment and monitoring in that subgroup.

Hickman to central venous catheter: A case of difficult venous access in a child suffering from acute lymphoblastic leukemia.

Chemotherapy in children suffering from cancer usually requires placement of an indwelling central venous catheter (CVC). A child may need to undergo repeated procedures because of infection and occlusion of previous access devices. We present a case of CVC insertion in a child suffering from acute lymphoblastic leukemia where an innovative technique was employed.

Can combined paravertebral and erector spinae block provide perioperative analgesia for mastectomy with LD flap reconstruction surgery? An observational study.

Background: Mastectomy and breast reconstruction with latissimus dorsi myocutaneous flap (LDF) is a major surgery that covers eight or more dermatomes causing severe pain in the postoperative period. Objectives: We evaluated the analgesic effect of a hybrid technique of ultrasound-guided combined thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) in a single needle pass in ten consecutive patients scheduled for mastectomy with LDF reconstruction as a part of a multimodal analgesia regimen. Design: Prospective observational study. Setting: A tertiary-level cancer hospital in Eastern India. The study was conducted between 01/09/2023 and 20/12/2023. Patients: 10 consecutive consenting female patients of age between 18 and 75 years suffering from breast cancer, scheduled for a mastectomy with LDF reconstruction were recruited in this study, excluding patients with body mass index more than 40, coagulopathy or thrombocytopenia, skin conditions such as dermatitis, infection and so on, and known allergy to local anaesthetics (LAs). Interventions: The recruited patients received an ultrasound-guided combined thoracic paravertebral and erector spinae (COMPARES) block at the third thoracic (T3) level in a single needle pass, with 10 mL in the TPVB and 30 mL in the ESPB compartment, respectively, in a cephalad to caudad approach before induction of general anaesthesia. Main outcome measures: The primary endpoint was pain score at 9:00 am on postoperative day one. Other outcome measures were pain scores at postoperative hours 0 (immediately after awakening from general anaesthesia), 4, 8 and 12, postoperative nausea vomiting, requirement of rescue analgesics and pain score on shoulder movements on postoperative day one. Results: Median (range) resting pain scores at 0, 4, 8 and 24 hours were 1.5 (0-5), 2.5 (0-4), 2.5 (2-5) and 3 (2-4), and dynamic pain score on shoulder mobilization on postoperative day one morning was 3 (2-6). Only one patient required rescue analgesia. Conclusions: We found the technique inexpensive and potentially useful, but difficult in obese and short-statured patients due to increased depth and narrowing of the intertransverse space. This technique should be further evaluated in a randomised controlled trial. Trial registration: This trial was registered with the Clinical Trials Registry of India with the registration number CTRI/2023/08/057119.

Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective.

The COVID-19 outbreak is on the world. While many countries have imposed general lockdown, emergency services are continuing. Healthcare professionals have been infected with the virulent severe acute respiratory syndrome coronavirus-2 (SARS), which spreads by close contact and aerosols. The anesthesiologist is particularly vulnerable to aerosols while performing intubation and other airway related procedures. Regional anesthesia (RA) minimizes the need for airway manipulation and the risks of cross infection to other patients, and the healthcare personnel. In this context, for prioritizing RA over general anesthesia, wherever possible, a structured algorithmic approach is outlined. The role of percentage saturation of hemoglobin with oxygen (oxygen saturation), blood pressure and early use of point-of-care ultrasound in differential diagnosis and specific management is detailed. The perioperative anesthetic implications of multisystem manifestations of COVID-19, anesthetic management options, the scope of RA and considerations for its safe conduct in operating rooms is described. An outline for safe and rapid training of healthcare personnel, with an Entrustable Professional Activity framework for ascertaining the practice readiness among trained residents for RA in COVID-19, is suggested. These are the authors' experiences gained from the current pandemic and similar SARS, Middle East Respiratory Syndrome and influenza outbreaks in recent past faced by our authors in Singapore, India, Hong Kong and Canada.

Ultrasound-guided modified serratus anterior plane block for perioperative analgesia in breast oncoplastic surgery: A case series.

Ultrasound-guided serratus anterior plane (SAP) block has been described to provide complete anaesthesia and analgesia to the lateral thoracic wall. Its use has been recently reported in breast reconstruction surgeries. We present a series of 11 patients where ultrasound-guided SAP block was used as part of multimodal analgesia in breast reconstruction surgery using latissimus dorsi (LD) myocutaneous flap after mastectomies. This resulted in excellent analgesia in the perioperative period and minimal use of intravenous analgesics. The SAP block technique described here is safe and also provides effective analgesia in breast reconstruction surgery with LD flap.

Ultrasonographic assessment of altered anatomical relationship between internal jugular vein and common carotid artery with supraglottic airway in children: LMA vs i-gel™.

BACKGROUND AND AIMS: Use of ultrasound (US) during internal jugular vein (IJV) cannulation reduces the risk of associated complications in children under general anaesthesia. We studied the effect of two varieties of supraglottic airway device (SGAD), the Ambu AuraOnce™ LMA (Ambu LMA), and i-gel™ on the anatomical relationship between IJV and common carotid artery (CCA). Both these SGAD are known to have similar safety profile in paediatric age group. METHODS: A total of 62 children were randomly allocated into 2 groups. In group L: Ambu AuraOnce™ LMA (Ambu LMA) and in group I: i-gel™ was inserted. After induction of GA, US images were taken with head in neutral and 30 degrees rotated to the opposite side both before and after insertion of SGAD. The relationship between IJV and CCA was noted as lateral, anterolateral, and anterior. Degree of overlap between the two vessels was also noted. RESULTS: Lateral rotation of the head significantly alters the relationship between the IJV and CCA and also increases the degree of overlap between them. Though these changes were noted to be similar with both varieties of SGAD, but between the two varieties of SGAD, these changes were significantly higher in group I. CONCLUSION: Higher oesophageal sealing pressure exerted by i-gel™ as compared to other SGAD might cause increased distortion of the surrounding soft tissue leading to altered anatomical relationship between IJV and CCA, which makes the CCA vulnerable to puncture during IJV cannulation using landmark technique.

Ultrasound-guided truncal blocks: A new frontier in regional anaesthesia.

The practice of regional anaesthesia is rapidly changing with the introduction of ultrasound into the working domain of the anaesthesiologist. New techniques are being pioneered. Among the recent techniques, notable are the truncal blocks, for example, the transversus abdominis plane block, rectus sheath block, hernia block and quadratus lumborum block in the abdomen and the pectoral nerves (Pecs) block 1 and 2, serratus anterior plane block and intercostal nerve block. This narrative review covers the brief anatomical discourse along with technical description of the ultrasound-guided truncal blocks.

Ultrasound-Guided Temporomandibular Joint Injection for Chronic Posthemimandibulectomy Jaw Pain.

Temporomandibular joint (TMJ) pain can be difficult to diagnose and treat. We describe a patient with left jaw pain after right hemimandibulectomy. The patient was initially managed conservatively, which failed to reduce pain. He was then administered inferior alveolar nerve block and TMJ injection with steroid and local anesthetic. These injections provided temporary pain relief that lasted approximately 1 month and the pain recurred. Computed tomography scan showed lateral displacement of left mandibular condyle. He was then given ultrasound-guided TMJ injection of steroid and local anesthetic. This injection provided lasting pain relief.

COMBIPECS, the single-injection technique of pectoral nerve blocks 1 and 2: a case series.

Ultrasound-guided Pecs block can provide perioperative analgesia for breast surgery. A single-injection technique (COMBIPECS) combines both Pecs 1 and Pecs 2 blocks in a single needle pass. This technique saves time and is equally effective as the modified Pecs block which uses 2 needle passes. We present a case series of 21 patients who received the COMBIPECS block as a part of multimodal analgesia for breast cancer surgery. The block was administered before the surgery after induction of general anesthesia. The patients needed minimal intraoperative analgesics and remained pain free in the postoperative period up to 24 hours after surgery.

Modelling of microalgal growth and lipid production in Dunaliella tertiolecta using nitrogen-phosphorus-potassium fertilizer medium in sintered disk chromatographic glass bubble column.

A comprehensive mathematical model involving NPK-10:26:26 fertilizer, NaCl, NaHCO3, light and temperature operating variables for Dunaliella tertiolecta cultivation is formulated to predict microalgae-biomass and lipid productivity. Proposed model includes Monod/Andrews kinetics for the absorption of essential nutrients into algae-biomass and Droop model involving internal nutrient cell quota for microalgae growth, assuming algae-biomass is composed of sugar, functional-pool and neutral-lipid. Biokinetic model parameters are determined by minimizing the residual-sum-of-square-errors between experimental and computed microalgae-biomass and lipid productivity using genetic algorithm. Developed model is validated with the experiments of Dunaliella tertiolecta cultivation using air-agitated sintered-disk chromatographic glass-bubble column and the effects of operating variables on microalgae-biomass and lipid productivity is investigated. Finally, parametric sensitivity analysis is carried out to know the sensitivity of model parameters on the obtained results in the input parameter space. Proposed model may be helpful in scale-up studies and implementation of model-based control strategy in large-scale algal cultivation.

Ultrasound-Guided Serratus Anterior Plane Block in Breast Reconstruction Surgery.

Pecs block and its variations have been used for various breast surgeries. We describe 2 cases of mastectomy and breast reconstruction by latissimus dorsi (LD) flap where regional analgesia was provided by a combination of ultrasound-guided Pecs-I block and serratus anterior plane block, a recently described technique in which local anesthetic is deposited in the plane between the LD and serratus anterior muscle. This resulted in excellent intraoperative and postoperative analgesia and a minimum of systemic analgesics. The described technique is safe to administer and provides good analgesia for breast reconstruction surgery by LD flap.

Comparison of ultrasound imaging in transverse median and parasagittal oblique planes for thoracic epidurals: A pilot study.

BACKGROUND AND AIMS: The use of ultrasound (US) scanning to assess the depth of epidural space to prevent neurological complications is established in current practice. In this study, we hypothesised that pre-puncture US scanning for estimating the depth of epidural space for thoracic epidurals is comparable between transverse median (TM) and paramedian sagittal oblique (PSO) planes. METHODS: We performed pre-puncture US scanning in 32 patients, posted for open abdominal surgeries. The imaging was done to detect the depth of epidural space from skin (ultrasound depth [UD]) and needle insertion point, in parasagittal oblique plane in PSO group and transverse median plane in TM group. Subsequently, epidural space was localised through the predetermined insertion point by 'loss of resistance' technique and needle depth (ND) to the epidural space was marked. Correlation between the UD and actual ND was calculated and concordance correlation coefficient (CCC) was used to determine the degree of agreement between UD and ND in both the planes. RESULTS: The primary outcome, i.e., the comparison between UD and ND, done using Pearson correlation coefficient, was 0.99 in both PSO and TM groups, and the CCC was 0.93 (95% confidence interval [95% CI]: 0.81-0.97) and 0.90 (95% CI: 0.74-0.96) in PSO and TM groups respectively, which shows a strong positive association between UD and ND in both groups. CONCLUSION: The use of pre-puncture US scanning in both PSO and TM planes for estimating the depth of epidural space at the level of mid- and lower-thoracic spine is comparable.

Ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a pediatric patient.

Quadratus lumborum block is a recently introduced variation of transversus abdominis plane block. In this report, we describe the use of ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a 7-year-old child scheduled to undergo radical nephrectomy (left-sided) for Wilms tumor. The result was excellent postoperative analgesia and minimal requirement for rescue analgesics. The modification described may allow easier placement of a catheter for continuous infusion of local anesthetic.

Regional anaesthesia for surgical repair in selected open globe injuries in adults.

PURPOSE: To determine whether the combination of topical, intracameral and facial nerve blocks would produce adequate analgesia for repair of open globe injuries without increasing intraocular tension. METHODS: A comparison of combined O'Brien's block (facial nerve block), topical ropivacaine and intracameral lignocaine versus peribulbar block in 100 randomly selected cases of traumatic corneal rupture. Patients were randomly divided in two groups of 50 each based on those receiving the combined approach (Group T) and those undergoing peribulbar block (Group P). Patients were excluded if there was rupture with significant scleral extension, the interval between trauma and presentation greater than 2 h, presence of hypopyon, rupture with significant corneal oedema, expulsion of intraocular contents with a collapsed globe and monocular cases. The effect of the anaesthetic was compared by patient comfort and surgeon comfort, the incidence of vitreous prolapse and the requirement of incremental sedation. The Student's "t" test, the "Z" test, and Chi Square tests were used where appropriate. P < 0.05 was considered statistically significant. RESULTS: The average patient comfort in Group P was 5.67% greater than Group T (P > 0.05). The average surgeon comfort and patient comfort between groups were similar (P > 0.05, both comparisons). Incremental sedation was required in 16% of patients in Group T compared to 8% in Group P (P = 0.218363). The total sedation dosage required for each group was similar. The incidence of vitreous prolapse was statistically significantly higher by 14% in Group P compared to Group T (P = 0.03731). CONCLUSIONS: Our combined technique proved as efficacious as peribulbar block in providing adequate local anaesthesia and reducing the incidence of vitreous prolapse. We recommend greater use of this technique for repair of open globe injuries especially in locations where full time anaesthesia services are not available.

Fibromyalgia and myofascial pain syndrome-a dilemma.

SUMMARY: Pain and fatigue associated to the musculoskeletal system are among the leading causes of patients to visit their physicians and nearly one-third of such patients suffer from fibromyalgia. Fibromyalgia syndrome (FMS) is a chronic debilitating disorder characterized by widespread pain with tenderness in specific areas, leading to fatigue, headache and sleep disorder. Myofascial Pain Syndrome (MPS), is also a localized musculoskeletal pain producing condition whose diagnostic and management criteria differ from FMS but still considered by many only a subtype of FMS. Till date no exact cause has been held responsible for these painful conditions, therefore treatment of these disorders is always a challenge. The therapies are not precise but multimodal including pharmacological and alternative approaches. This article describes the existing knowledge pertaining to these conditions in regard of causative factors diagnosis and management.