Comparison of analgesic efficacy of ultrasound-guided quadratus lumborum block versus erector spinae plane block in children undergoing elective open pyeloplasty - A randomized, double-blinded, controlled study.

Background and Aims: Comparison of analgesic efficacy of ultrasound-guided transmuscular quadratus lumborum block (QL-3) and erector spinae block (ESP) in children undergoing open pyeloplasty was done in this study. Material and Methods: This was a randomized, double-blinded, controlled study conducted in a tertiary care center, operating rooms, post-anesthesia care unit (PACU), and paediatric surgical ward. Sixty children of age 1-6 years, with American Society of Anesthesiologists (ASA) status I or II, undergoing elective open pyeloplasty were included in the study. Patients were randomized into two groups: group I (QL block-3) and group II (ESP). Both blocks were performed under USG guidance using 0.5 ml/kg of 0.25% ropivacaine after induction of general anesthesia. Postoperative Modified Objective Pain Score (MOPS), perioperative hemodynamic parameters, perioperative time for first rescue analgesia, total rescue analgesia, and incidence of complications were recorded. Statistical tests were applied as follows: (i) quantitative variables were compared using independent t-test/Mann-Whitney test (when the data sets were not normally distributed) between the two groups, and repeated measure analysis of variance (ANOVA)/Friedman test was used for comparison between different time intervals within the same group and (ii) qualitative variables were correlated using the Chi-square test/Fisher's exact test. A P value of <0.05 was considered statistically significant. Results: Pain was assessed using MOPS in the postoperative period at 0, 30 min, 1, 2, 4, 6, 12, and 24 h. Overall, the pain scores were low and showed a decreasing trend toward baseline as time progressed. Group I showed lower score, but was statistically significant only at the sixth hour. Highest mean score was 2.4 ± 2.01 in group I and 2.67 ± 2.32 in group II. Perioperative hemodynamic parameters were comparable. Total rescue analgesia during the perioperative period was not statistically significant (intraoperative P = 0.075 and postoperative P = 0.928). Also, 63.33% patients in group I and 63% patients in group II required rescue analgesia in the postoperative period and were comparable. Mean ± standard deviation (SD) for first rescue analgesia time was 6.32 ± 12.57 in group I and 16.67 ± 31.25 in group II, but not significant. The distribution in group II was skewed, hence the larger value for group II, but when compared to group I, this was statistically not significant. Conclusion: Both ultrasound-guided ESP block and QL block using 0.25% ropivacaine 0.5 ml/kg provided adequate analgesia during the first 24 h post-surgery in children undergoing open pyeloplasty. The fentanyl requirement during the first 24-h postoperative period was also decreased.

Efficacy of lignocaine nebulization in patients with COVID-19 respiratory infection: An exploratory randomized double-blinded controlled trial.

Background and Aims: Coronavirus disease (COVID-19)-related pneumonia is proposed to be an inflammatory process. The treatment currently includes supportive therapy and low-dose steroids. Anti-inflammatory drugs have been proposed to prevent cytokine storms and improve oxygenation in such cases. The study aimed to assess the efficacy of nebulized lignocaine in COVID-19 patients with pneumonia. Material and Methods: This was an exploratory randomized double-blinded control trial conducted in COVID-19 patients with respiratory failure requiring oxygen therapy either by face mask or non-invasive mechanical ventilation. Patients included were of the age of more than 18 years of either gender. The patients were randomized to receive either lignocaine or distilled water nebulization. The outcomes assessed were PaO2/FiO2 ratio, hemodynamics, respiratory parameters, and sequential organ failure score (SOFA). Results: The two groups were comparable concerning demographic variables. The PaO2/FiO2 were significantly higher in the lignocaine group from day 2 onward. The SPO2 was significantly higher on day 3 in the lignocaine group and thereafter there was no significant difference. Other hemodynamic, respiratory parameters, and SOFA scores showed no difference in both the groups. Conclusion: Lignocaine nebulization improved oxygenation in COVID-19 patients and can be used as adjunctive therapy along with other supportive medications.

The efficacy of ultrasound-guided upper thoracic erector spinae plane block for postoperative analgesia in proximal shoulder surgery and its effect on phrenic nerve function: A prospective exploratory study.

Background and Aims: The upper thoracic (T2) erector spinae plane block (UT-ESPB) has been proposed as an alternative to interscalene brachial plexus block for postoperative analgesia in shoulder surgery. The current study was conducted to evaluate the same. Material and Methods: Patients scheduled for shoulder surgery under general anesthesia (GA) received ultrasound-guided UT-ESPB. The outcomes measured were diaphragmatic movements, block characteristics, and quality of recovery at 24 h. Results: A total of 43 patients were recruited. The incidence of phrenic nerve palsy was 0%. The sensory level achieved by the maximum number of patients at the end of 30 min was C7-T5 level, and none had a motor block. Forty-two percent of patients did not require rescue analgesia till 24 h postoperative. In the rest of the patients, the mean (SD) duration of analgesia was 724.2 ± 486.80 min, and the mean postoperative requirement of fentanyl was 98.80 ± 47.02 µg. The median pain score (NRS) during rest and movement is 2 to 3 and 3 to 4, respectively. The median quality of recovery score at the end of 24 h after the block was 14 (15-14). Conclusion: The upper thoracic ESPB resulted in a sensory loss from C7-T5 dermatomes without any weakness of the diaphragm and upper limb. However, the block was moderately effective in terms of the total duration of analgesia, postoperative pain scores, analgesic requirement, and quality of recovery in patients undergoing proximal shoulder surgeries under GA. Further studies are required to establish its role due to its poor correlation with sensory spread.

Transforaminal Epidural Injection of Local Anesthetic and Dorsal Root Ganglion Pulsed Radiofrequency Treatment in Lumbar Radicular Pain: A Randomized, Triple-Blind, Active-Control Trial.

BACKGROUND: Lumbar radicular pain (LRP) results from inflammation and irritation of lumbar spinal nerves and the dorsal root ganglion (DRG). METHODS: Our study is a prospective, triple-blind, randomized, activecontrol trial (CTRI/2016/02/006666) comparing transforaminal epidural local anesthetic (LA) injection and pulsed radiofrequency treatment of DRG in patients with chronic LRP. Patients with LRP after failed conservative management for >3 months received selective diagnostic nerve root block with 1 mL 2% lidocaine. Fifty patients showing positive responses were divided into groups of 25 each. The LA group received transforaminal epidural injection of 1 mL 0.5% bupivacaine. The lumbar pulsed radiofrequency (LPRF) group received transforaminal epidural injection of 1 mL 0.5% bupivacaine with 3 cycles of pulsed radiofrequency of the DRG for 180 seconds RESULTS: Both groups were compared by observing pain intensity on a 0- to 100-point VAS and improvement in functional status by the Oswestry Disability Index (ODI version 2.0) at 2 weeks and 1, 2, 3, and 6 months. All baseline variables were comparable between the 2 groups. Statistically significant reduction in both outcomes was seen in the LPRF group compared to the LA group from 2 weeks to 6 months. One hundred percent of patients in the LPRF group had a ≥20- point decrease in VAS and significant percentage reduction in ODI at all time intervals up to 6 months, whereas it was seen in 80% and 28% of patients in the LA group at 3 and 6 months, respectively. No complications were seen in any patients CONCLUSION: Pulsed radiofrequency of the DRG applied for longer duration results in long-term pain relief and improvement in the functional quality of life in patients with chronic LRP.

Anesthetic management of pediatric patients with Sturge-Weber syndrome: our experience and a review of the literature.

INTRODUCTION: Sturge-Weber syndrome (SWS) is a rare sporadic congenital neurocutaneous syndrome which is characterized by vascular malformation involving the brain, face and eye. The anesthetic management is complicated by its localized as well as systemic manifestations, associated anomalies and difficult airway due to the presence of angiomas of the oral cavity and airway. We retrospective analyzed the perioperative anesthetic management of children with SWS undergoing ophthalmic surgery and reviewed the literature. METHODS: Medical records and anesthetic charts of all the children with SWS who had undergone an ophthalmic procedure under general anesthesia during the past 6 years were reviewed. Information related to the demographic profile, preoperative evaluation, anesthetic techniques, and perioperative complications were collected and analyzed. RESULTS: Forty children with SWS received general anesthesia for an ophthalmic procedure within the 6-year period. The median age of the children was 3 years. 30 (92.5%) children had facial port-wine staining, 10 (25%) had facial hypertrophy, 15 (37.5%) had a history of convulsion and 4 (10%) children had mental retardation. Inhalational induction was performed in 34 (85%) children (sevoflurane 82.8%). A laryngeal mask airway (LMA) and endotracheal tube were used in 32 (80%) and 5 (12.5%) cases, respectively. One patient had difficult mask ventilation and difficult LMA insertion. There was no significant problem in any of the other children. CONCLUSION: Preoperative evaluation with airway assessment should be performed with the knowledge of local and systemic manifestation of the syndrome. Proconvulsant and anticonvulsant properties of the anesthetics, as well as drug interactions of antiepileptic medications should be considered when planning anesthesia. Avoiding a rise in intracranial and intraocular pressures, vigilant intraoperative monitoring and postoperative care are the key for conducting safe anesthesia in these children. For ophthalmic procedures, LMAs can be used for airway maintenance with minimal complications in children with SWS.

Perioperative management and post-operative course in preterm infants undergoing vitreo-retinal surgery for retinopathy of prematurity: A retrospective study.

BACKGROUND: Premature infants scheduled for surgery under general anesthesia are more prone to cardio-respiratory complications. Risk factors include post-conception age (PCA), cardiac and respiratory disease, anemia and opioid administration. This retrospective study evaluates the perioperative management and post-operative course (apnea and bradycardia) in premature infants undergoing surgery for retinopathy of prematurity (ROP). MATERIALS AND METHODS: We analyzed the pre-operative data, anesthesia chart and post-operative course of 52 former premature infants for 56 general anesthesia exposures for ROP surgery. RESULTS: At the time of procedure, median PCA was 51 (36-60) weeks. 71% of the infants were above 46 weeks of PCA. Five infants had cardiac disease and four had a history of convulsion. Four infants had a pre-operative history of apneic spells. The airway was secured with either endotracheal tube (46) or supraglottic device (10). Fentanyl (0.5-1 µg/kg), paracetamol, topical anesthetic drops and/or peribulbar block were administered for analgesia. Extubation was performed in the operating room for 54 cases. Three infants had apnea post-operatively. Seven infants were shifted to neonatal intensive care unit either for observation or due to delayed recovery, persistent apneic spells and pre-existing cardio-respiratory disease. CONCLUSION: In the present study, intravenous paracetamol and topical anesthetics reduced the total intra-operative opioid requirement, which resulted in low incidence of post-operative apnea. Regional anesthesia may be considered in infants with high risk of post-operative apnea. Infants with PCA > 42 weeks and without any co-morbidity can be managed in post-anesthesia care unit.

A randomised trial comparing block characteristics of a mixture versus sequential injections of lignocaine and ropivacaine for supraclavicular brachial plexus nerve block in patients undergoing upper limb surgery.

Background and Aim: There is no consensus on the appropriate use of mixtures of local anaesthetic drugs in various combinations for nerve blocks. We intended to compare short-acting lignocaine and long-acting ropivacaine as a mixture versus undiluted sequential injections on block characteristics of ultrasound-guided (USG) supraclavicular brachial plexus block for upper limb surgeries. Methods: A double-blinded randomised study was conducted on 64 adult patients scheduled for upper limb surgery who received 15 mL each of 2% lignocaine with adrenaline and 0.75% ropivacaine as a 1:1 mixture in the mixed group (Group M) or sequential injections in the sequential group (Group S) by using a USG technique. The primary outcome was the percentage of participants with complete four nerve sensory blocks at 10 minutes post block injection. Secondary outcomes were sensory and motor block characteristics till 30 minutes, total duration of analgesia, sensory and motor block, and complications. Results: Demographic characteristics and time taken for the procedure were similar. The percentage of participants with a complete four-nerve sensory block at 10 minutes was higher in Group S (69%) versus Group M (41%) (P = 0.04). Complete sensory and motor block rates were similar at 30 minutes. The block procedure time, total duration of analgesia, and sensory and motor block were similar in both groups. There were no major complications. Conclusion: Sequential lignocaine-ropivacaine, compared to the mixed injection technique, has a higher initial rate of sensory and motor block onset with a similar total block duration.

Incidence, risk factors, and outcomes of acute kidney injury in patients undergoing emergency laparotomy - A prospective observational exploratory study.

Background and Aims: Acute kidney injury (AKI) can occur in post-laparotomy patients, with a variable incidence. This study aimed to determine the incidence of AKI in patients undergoing emergency laparotomy under general anaesthesia, the effect of preoperative variables on the development of AKI, and the association of post-operative AKI with patient outcomes. Methods: This prospective exploratory study in patients undergoing emergency laparotomy was followed up for 7 days to determine the incidence of post-operative AKI. We determined the patients developing different severity of AKI based on kidney disease improving global outcome staging. Fisher's exact test or Chi-squared test was used to study the association of demographic variables, and various periopertaive variables on the development of postoperative AKI. The association of AKI with the duration of hospital stay was estimated using the Wilcoxon-Mann-Whitney U Test, and Fisher's exact test was used to study the association between AKI and mortality. Results: No patient had AKI in the pre-operative period. On day 3, 18 patients; on day 5, 28 patients; and on day 7, 24 patients developed AKI. Overall, a maximum of 33 patients (out of 100) developed AKI at any time. Our study found that the American Society of Anesthesiologists (ASA) IV and sepsis were independent risk factors for post-operative AKI. Our results also show a moderate-to-high independent association between AKI and duration of hospital stay and mortality (within 30 days). Conclusion: Incidence of post-operative AKI following emergency laparotomy was 33%. Higher preoperative ASA physical status and sepsis were significantly associated with postoperative AKI development.

Comparison of block characteristics and outcomes in opioid-free and opioid-based thoracic continuous spinal anaesthesia in patients undergoing major abdominal surgery: A double-blinded randomised controlled trial.

Background and Aims: Thoracic continuous spinal anaesthesia (TCSA) is emerging as the sole anaesthetic for major abdominal surgery due to its better perioperative outcomes. This study was designed to evaluate block characteristics and outcomes in 'opioid-free' and 'opioid-based' TCSA. Methods: After ethical approval, trial registration and written informed consent, 50 adult patients undergoing major abdominal surgery were randomised into 'opioid-free' (bupivacaine alone) and 'opioid-based' (bupivacaine with fentanyl) groups. After confirmation of T4-L1 dermatome level of spinal anaesthesia, sedation by intravenous (IV) midazolam (0.02-0.05 mg/kg), ketamine (0.25 mg/kg) and dexmedetomidine (bolus dose of 1 µg/kg IV over 10 min followed by 0.2-0.7 µg/kg/h infusion) were started. The primary outcome measured was postoperative pain scores for 72 h in both groups. The secondary objectives were rescue opioid requirement, and the dose of bupivacaine required to achieve T4 level. Data were compared using the two-sided Student t-test, Mann-Whitney and Fisher's exact tests. Results: The 'opioid-based' group performed significantly better compared with the 'opioid-free' group concerning pain scores at rest at 0 h (P = 0.023), 18 h (P = 0.023) and 24 h (P = 0.016) postoperatively, decreased intrathecal bupivacaine requirement [(induction (P = 0.012) and maintenance (P = 0.031)], postoperative rescue fentanyl requirement (P = 0.018) and patient satisfaction (P = 0.032) at the cost of increased postoperative nausea and vomiting (P = 0.049). Conclusion: The 'opioid-based' TCSA provided better postoperative analgesia with significantly lesser postoperative pain scores when compared to the 'opioid-free' group in patients undergoing major abdominal surgery.

Perioperative concerns in pediatric patients u10/1/2013ndergoing different types of scoliosis correction surgery: A retrospective observational study.

BACKGROUND: Advances in scoliosis surgery have now made it possible for younger patients to be taken up for scoliosis correction. OBJECTIVES: To ascertain the patient profile, perioperative complications and need for intensive care management in children undergoing posterior fusion and instrumentation (PF), anterior release (AR), and growth rod (GR) insertion surgery. PATIENTS AND METHODS: After taking parental consent, data were collected retrospectively for 33 patients who underwent 37 procedures (four patients had both anterior and posterior procedures) on 2 days of the week mainly from August 2008 to February 2010 at a tertiary care institution. RESULTS: Children undergoing GR surgery were younger (8.1 ± 2.1 years) than patients undergoing AR (12.9 ± 1.7 years) or posterior fusion (14.2 ± 2.2 years). AR children had a significantly higher Cobb's angle and more rigid curves. (P = 0.057) Associated congenital abnormalities especially neurological were commoner in the GR children. Surgical duration and blood loss was significantly more for PF (2207.5 ± 1224.13 ml) than GR (456 ± 337.5 ml), or AR (642.85 ± 304.72 ml), (P = 0.0002). PF patients needed Intensive care unit (ICU) care mainly due to the blood loss and prolonged surgery (35%). AR performed via thoracotomy was associated with the need for mechanical ventilation in 28.6%. The GR patients had major intraoperative hemodynamic events and 20% needed ICU care. CONCLUSIONS: Post-operative ventilation may be required in 20-35% patients undergoing procedures for scoliosis correction. Despite GR insertion involving lesser blood loss; younger age, congenital abnormalities, positioning, and surgical manipulation resulted in life threatening events in these patients.

Comparison of continuous transmuscular quadratus lumborum block and continuous psoas compartment block for posterior total hip arthroplasty: A randomised controlled trial.

Background and Aims: Analgesia for hip surgery involves cutaneous anaesthesia at the site of the skin incision and the anterior hip capsule. This study aimed to compare continuous ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) with psoas compartment block (PCB) for analgesia in patients undergoing total hip arthroplasty (THA) under general anaesthesia (GA). Methods: This randomised, observer-blinded trial included 18-70-year-old American Society of Anesthesiologists physical status I-III patients undergoing THA under GA with either US-guided continuous TQLB or PCB. Primary objectives included a visual analogue scale (VAS; 0-100 mm) at rest and mobilisation at 6 h postoperatively (analysed by intention to treat and per protocol) using a non-inferiority margin of 20 mm. Secondary objectives included VAS at other time points, 24-h fentanyl consumption (analysed using the Wilcoxon rank-sum test), sensory dermatomes anaesthetised, motor weakness 30 min after block, and haemodynamic response to skin incision (analysed using the Chi-squared or Fisher's exact test). A P value less than 0.05 was considered statistically significant. Results: VAS (0-100 mm) score at 6 h on rest was 25.34 ± 14.25 and 27.3 ± 9.6, mean difference (MD) was 1.9 [-3.3, 7.1] and at movement was 35.1 ± 23.0 and 38.6 ± 17.0, MD was 3.5 [-5.2, 12.2], in the PCB (n = 29) and QLB (n = 30) groups, respectively (i.e. less than the non-inferiority margin). However, VAS (rest) at 1, 12, and 24 h postoperatively and median (IQR) 24-h fentanyl consumption was significantly higher in the QLB group (1212.5 [300-2345] µg] when compared to the PCB group (635 [100-1645] µg; P = 0.0004). Conclusion: Though statistically, continuous QLB was non-inferior to continuous PCB for pain at rest and mobilisation at 6-hours postoperatively, a higher 24-hour perioperative fentanyl consumption and VAS show that QLB was clinically inferior to PCB.

Comparison of Prophylactic Infusion of Phenylephrine Versus Norepinephrine for the Prevention of Post Spinal Hypotension in Parturients Undergoing Elective Caesarean Section-a Randomized, Double-Blinded, Non-Inferiority Trial.

Objective: Postspinal hypotension occurs in nearly 50% of women undergoing cesarean section (CS). Although phenylephrine (PE) is currently the vasopressor of choice, severe maternal bradycardia may adversely affect the fetal status due to the reduction in the maternal cardiac output. Norepinephrine (NE) is not associated with bradycardia and is now being evaluated for the treatment of post-spinal hypotension in obstetric patients. The hypothesis of this study was that the prophylactic NE infusion was non-inferior to PE infusion when used for the prevention of postspinal hypotension. Methods: This was a randomized, double-blinded controlled study conducted in 130 parturients scheduled for CS. The participants received either prophylactic NE (5 µg min-1) or PE (25 µg min-1) infusion beginning at the time of spinal injection. The primary outcome was the incidence of hypotension in both groups. Maternal bradycardia, reactive hypertension, nausea and vomiting, requirement of rescue boluses of vasopressor and/or atropine, and neonatal acid base status were also recorded. Results: The incidence of hypotension was 33.80% (22 of 65) in Group PE and 26.10% (17 of 65) in Group NE (P=0.85). The absolute risk difference [90% confidence interval (CI)] in the incidence of hypotension between the groups was -7.7% (-20.9, 5.4). The upper limit of the CI was less than the non-inferiority margin of 20%, indicating that the NE infusion was non-inferior to PE. Conclusion: Prophylactic infusion of NE is not inferior to prophylactic PE infusion in the prevention of postspinal hypotension in patients undergoing CS.

Recovery time in target controlled infusion versus manual infusion of propofol in total intravenous anaesthesia for endoscopic retrograde cholangio-pancreatography procedure using laryngeal mask airway-gastro: A randomised comparative study.

Background and Aims: This study aimed to compare manual infusion versus target-controlled infusion (TCI) in total intravenous anaesthesia (TIVA) utilising laryngeal mask airway (LMA)-gastro during endoscopic retrograde cholangio-pancreatography (ERCP) procedures. Methods: This was a single-blind randomised trial. Patients were randomly allocated into two groups. TCI group included 27 patients, where TCI of propofol was implemented with the Schnider pharmacokinetic model driven by a computer-controlled syringe pump. The TIVA group included 27 patients with a loading dose of 2 mg/kg of propofol, followed by manual infusion of 15 mg/kg/h for the first 15 min, 13 mg/kg/h for the next 15 min, then 11 mg/kg/h for 30 min and 10 mg/kg/h for 60 min and finally maintained at 9 mg/kg/h. The primary objective was to compare recovery time following cessation of propofol infusion in both groups. The difference in the total dose of propofol, time to achieve anaesthesia induction, first attempt success rate, ease of LMA-gastro insertion, ease of insertion, success rate of endoscope device and post-anaesthesia care unit (PACU) discharge time were the secondary objectives. T-test and Chi-square test were used for statistical analysis. Results: The time required for the recovery was significantly less in the TCI group than in the TIVA group (mean ± standard deviation; 11.60 ± 2.27 versus 15.4 ± 3.25 minutes, P < 0.001). The duration of ERCP, ease of LMA and endoscope insertion were comparable between the groups. There was no post-operative recall of intra-operative events in the groups. Conclusion: TCI offers earlier recovery than TIVA in patients undergoing ERCP procedures using LMA-gastro.

Role of Preoperative Oral Rehydration Solution on Myocardial Ischaemia During Orthopaedic Surgery under Spinal Anaesthesia: A Prospective Randomised Study.

Objective: Preoperative oral rehydration solution (ORS) supplementation offers wide postoperative benefits, but its role in reducing post-spinal myocardial ischaemia is uncertain. We evaluated this aspect in elective lower limb orthopaedic surgeries and compared it to conventional preoperative fasting. Methods: Prospectively, we randomised 126 patients aged >60 years into two groups: (A) received reconstituted ORS (1000 mL) during the overnight preoperative fasting, continued up to 2 hrs prior to spinal anaesthesia (SA) induction; (B) kept on conventional overnight preoperative fasting. This study evaluated electrocardiographic ischaemic changes at 2, 5, 10, 15, and 30 minutes after SA induction. Results: In total, 27 patients (group A: 7; group B: 20) developed transient electrocardiographic ischaemic changes. On intergroup comparison, group B had a significantly higher incidence at all time points, with highest statistical levels at 5- and 10-minutes ((P < 0.001). The receiver operating characteristic curve at a threshold fasting duration (fluids) of >3 hours, had an area-under-curve of 0.74 to predict such changes within 30 minutes of SA induction (sensitivity 96.30%, specificity 55.56%, accuracy 64.29%, odds ratio 32.50, relative risk 20.80, (P < 0.001). Post-spinal hemodynamic changes were higher in group B than in A; hypotension and tachycardia were statistically significant ((P=0.020). The pleth variability index was significantly higher ((P < 0.001), while perfusion index was significantly lower (P < 0.001) in group B at all time points. Conclusion: Preoperative ORS supplementation significantly reduced post-spinal transient ischaemic electrocardiographic changes in elderly patients than conventional overnight fasting.

Efficacy of stellate ganglion interventions for complex regional pain syndrome in the upper limb-A systematic review and meta-analysis.

Background and Aims: Stellate ganglion (SG) interventions for treating upper limb complex regional pain syndrome (CRPS) have been reported in studies. However, more substantial evidence is required to reach a consensus on its analgesic efficacy. To the best of our knowledge, no systematic review demonstrating the effectiveness of SG intervention for upper limb CRPS has been reported. Hence, this meta-analysis was done to ascertain the efficacy of SG intervention in managing patients with upper limb CRPS. Methods: A database search of PubMed, Cochrane, Embase, Scopus and Google Scholar was done for articles published between January 2001 and December 2021. Two independent reviewers extracted data from the included studies, and the studies were evaluated for any potential risk of bias, and a meta-analysis was performed. Results: Eight studies were included in the qualitative synthesis, four were randomised controlled trials (RCTs), and the rest were non-RCTs. Six studies were assessed quantitatively. A significant reduction in pain scores post-intervention, up to two weeks, and four to 28 weeks after the procedure was observed, although the included studies exhibited marked heterogeneity. Qualitative analysis of these studies revealed an overall improvement in disability scores and functionality as assessed by an improved range of motion. Most studies reported no complications or only short-term minor complications after the procedure. Conclusion: Stellate ganglion interventions improve pain and disability scores with self-limiting short-term complications and no long-term complications. However, further studies with a large sample size are required to validate this treatment modality.

Peripheral nerve blocks for the management of lumbo-sacral radiculopathy: A prospective study.

Background: The epidural injections used to treat lumbar radiculopathy are potentially associated with serious complications like neurological injuries and epidural abscess. The nociceptors have the unique property of being pseudo-unipolar, as its both ends are expected to be functionally same. We have hypothesized that peripheral nerve blocks given at the distal site should be able to provide pain relief. This prospective study was planned to assess the efficacy of peripheral nerve blocks in lumbar radiculopathy. Methods: Thirty-four patients who fit the eligibility criteria were included in this open labeled prospective preliminary study. They were administered peripheral nerve blocks at ankle level with 4 ml of 0.25% bupivacaine and 40 mg of triamcinolone. Outcomes measured: The outcomes measured at 15 days, 1 month, 2 months, and 3 months after the intervention were the pain intensity (Numerical Rating Scale), the Global Perceived Effect, functional status (Roland Morris Disability Questionnaire), Beck's Depression Inventory score, employment status, and analgesic intake. Results: At 15 days, 1 month, and 2 months, 88% of the patients reported a ≥50% decrease in their pain scores and a GPE ≥6, while at 3 months 85% of the patients reported a significant decrease in their pain scores and a GPE ≥6. Conclusion: Peripheral nerve blocks are effective in the management of pain in patients with chronic lumbosacral radiculopathy. The ability to administer it in an outpatient setting, without image guidance and the absence of debilitating side effects, makes it an attractive treatment option.

Effect of autologous platelet-rich plasma (PRP) on low back pain in patients with prolapsed intervertebral disc: A randomised controlled trial.

Background and Aims: Prolapsed intervertebral disc (IVDP) is a major cause of low back pain. Platelet-rich plasma (PRP) has emerged as a viable option for these patients, with fewer adverse effects and long-term sustainability of pain relief. This double-blinded, randomised study aimed to evaluate the effect of autologous PRP on low back pain in patients with IVDP. Methods: A total of 42 patients with IVDP were randomised either to the autologous PRP (n = 21) group or control (epidural local anaesthetics with steroids; n = 21) group. Change in pain was assessed using the Numeric Rating Scale (NRS). Impact of treatment was assessed using the Global Perceived Effect (GPE) scale. All the patients were followed up for six months. Data was compared using Chi-square, independent sample t, and Mann-Whitney U tests. Results: The two groups were similar in their demographic and clinical profile. The baseline mean NRS ± standard deviation (SD) was 6.91 ± 0.94 in the PRP group and 7.38 ± 1.16 in the control group (P = 0.099). At six months, the mean NRS ± SD was 1.43 ± 0.75 in the PRP group compared to 5.43 ± 0.75 in the control group (P < 0.001). The GPE score was also found to be significantly higher in the PRP group, compared to the control group in the final assessment (P < 0.001). During the course of the study, the PRP group showed a consistent decline in NRS, whereas the control group showed an initial decline followed by consistent increase in NRS. Conclusion: PRP provided sustained relief from low back pain due to IVDP and can be recommended as a safe and promising alternative to epidural local anaesthetics and steroids.

A Randomized Trial to Compare Ultrasound-Guided Dorsalis Pedis Versus Posterior Tibial Artery Cannulation in Neurosurgical Patients.

Introduction Dorsalis pedis or posterior tibial artery is selected as an alternative to radial artery cannulation when there is no access or unsuccessful cannulation of a radial artery. This study aimed to compare the two major arteries of the foot (dorsalis pedis and posterior tibial) in terms of their ultrasound (USG)-guided cannulation characteristics in patients posted for elective neurosurgical procedures. Methods All consenting patients, 18-65 years of age, scheduled for elective neurosurgical procedures under general anesthesia requiring arterial cannulations were enrolled. The first-pass success rate, assessment time, cannulation time, total procedural time, and the number of cannulation attempts for both procedures were estimated. Results A total of 90 patients were included in the study. The assessment time, cannulation time, and total time for arterial cannulation were significantly greater in the dorsalis pedis artery group than in the posterior tibial artery group (p < 0.001). Successful arterial cannulation in the first attempt was 73.3% in the dorsalis pedis, whereas it was 80% in the posterior tibial group but comparable (p = 0.455). The successful cannulation outcome was slightly more in the posterior tibial artery group but comparable (p = 1.00). Conclusion First-pass successful cannulation rates in the posterior tibial and the dorsalis pedis artery are comparable. However, the assessment time, cannulation time, and total procedural time are higher and statistically significant for dorsalis pedis artery cannulation compared to the posterior tibial artery group.

A Retrospective Study to Evaluate the Perioperative Clinical Characteristics and Outcomes of Rhino-Orbital Cerebral Mucormycosis in COVID-19 Patients at a Tertiary Care Hospital in India.

Background and aims A descriptive analysis of patients who underwent surgical debridement for coronavirus disease 2019 (COVID-19) related mucormycosis was described, which aimed at the evaluation of perioperative clinical characteristics, perioperative complications, and outcomes. Methods We conducted a retrospective study on patients who underwent surgical intervention for mucormycosis during the COVID-19 pandemic at a tertiary care institute in India from March 1, 2021, to June 30, 2021. The medical records of 92 patients were reviewed and analyzed. Results There was a male predominance with a mean age of 50.86 years. The most common comorbidity was diabetes mellitus (DM) (98.9%). Intra-operative complications included hypotension, hyperglycemia, and hypokalemia. Most of the patients (88%) were extubated inside the operation theater, and 48% of patients had mortality. Serum ferritin levels, computed tomography severity score (CTSS), and D-dimers were significantly high in the patient who had mortality. Conclusion The perioperative mortality in patients with COVID-19 associated mucormycosis was very high. DM was the most common comorbidity followed by hypertension. Pre-operative elevated serum ferritin, D-dimer, and high CTSS were associated with higher mortality; hypokalemia, followed by hypocalcemia, was the most common perioperative and post-operative electrolyte imbalance. Thorough pre-operative optimization, multidisciplinary involvement, and perioperative care are of the utmost importance to decrease mortality and improve outcomes.