Use of intermediate cervical plexus block in carotid endarterectomy -an alternative to deep cervical plexus block: a case series.

INTRODUCTION: Carotid endarterectomy is performed for patients with symptomatic carotid artery occlusions. Surgery can be performed under general and regional anesthesia. Traditionally, surgery is performed under deep cervical plexus block which is technically difficult to perform and can cause serious complications. This case series describes 5 cases in which an intermediate cervical plexus block was used in combination with a superficial cervical plexus block for Carotid endarterectomy surgery. METHODS: Five patients who were classified as American Society of Anesthesiologists 2-3 were scheduled for Carotid endarterectomy due to symptoms and more than 70% occlusion of the carotid arteries. The procedures were carried out in the University Teaching Hospital- Peradeniya, Sri Lanka. All patients were given superficial cervical plexus block followed by intermediate cervical plexus block using 2% lignocaine and 0.5% plain bupivacaine. RESULTS: Adequate anesthesia was achieved in 4 patients, and local infiltration was necessary in 1 patient. Two patients developed hoarseness of the voice, which settled 2 h after surgery. Hemodynamic fluctuations were observed in all 5 patients. No serious complications were observed. All 5 patients had uneventful recoveries. DISCUSSIONS: Regional anesthesia for CEA is preferable in patients who are medically complicated to undergo anesthesia or in patients for whom cerebral monitoring is not available. Intermediate cervical plexus block is described for thyroid surgeries in literature, but not much details on its use for carotid surgeries. Deep cervical plexus blocks has few serious complications which is not there with the use of ICPB making it a good alternative for CEA surgeries . CONCLUSIONS: Superficial cervical plexus block and intermediate cervical plexus block can be used effectively for providing anesthesia for patients undergoing Carotid endarterectomy. It is safe and easier to conduct than deep cervical plexus block and enables monitoring of cerebral function.

Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study.

OBJECTIVES: Bowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23-40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy. METHODS: We performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening. RESULTS: Combined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes. CONCLUSIONS: ESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

Different Outcomes of "Silent Hypoxia" in Patients with COVID-19 Pneumonia: A Case Series and Literature Review.

COVID-19 has been declared a pandemic since March 2020 and it has been responsible for millions of deaths worldwide. The SARS-CoV-2 causes a spectrum of diseases mainly affecting the respiratory system. It can also complicate other systems causing thromboembolic phenomena and myocardial ischaemia. An entity of hypoxia has been described in these patients which show no clinical signs and symptoms of respiratory distress despite being extremely hypoxic. This is called silent or happy hypoxia. The exact mechanism for this is not known. We report 4 cases which had similar presentations of silent hypoxia but had different course of illness and different outcomes. All 4 patients did not show any signs of respiratory distress, but had oxygen saturation less than 82%. 3 of them needed intensive care unit support for oxygen therapy and subsequently needed noninvasive ventilation. Only one required invasive ventilation. The fourth patient did not require intensive care support. The patient who required invasive ventilation succumbed due to severe COVID pneumonia whereas the other 3 patients were discharged from the hospital. Silent hypoxemia can go undetected in COVID-19 patients particularly in the time of a pandemic. This case series highlights the importance of meticulous clinical examination including oxygen saturation measurements in suspected or confirmed patients with COVID-19. The course of illness can be different in different populations, and this needs further clinical evidence.

Incidence and effects of Varicella Zoster Virus infection on academic activities of medical undergraduates--a five-year follow-up study from Sri Lanka.

BACKGROUND: The adult population in Sri Lanka is having high level of susceptibility for Varicella Zoster Virus (VZV) infection. Among medical undergraduates, 47% are VZV seronegative. The purpose of the present study was to determine the incidence of VZV infection in medical undergraduates in Sri Lanka, and to describe the effects of VZV infection on their academic activities. METHODS: A retrospective cohort of medical undergraduates' susceptible for VZV infection was selected from the University of Peradeniya, Sri Lanka. Data on the incidence of VZV infection (Chickenpox) during their undergraduate period was collected using a self-administered structured questionnaire. A second questionnaire was administered to collect data on the details of VZV infection and the impact of it on their academic activities. VZV incidence rate was calculated as the number of infections per 1,000 person years of exposure. Descriptive statistics were used to describe the impact of VZV infection on academic activities. RESULTS: Out of the 172 susceptible cohort, 153 medical undergraduates were followed up. 47 students reported VZV infection during the follow up period and 43 of them participated in the study. The cumulative incidence of VZV infection during the period of five and half years of medical training was 30.7%. Incidence density of VZV infection among medical undergraduates in this cohort was 65.1 per 1,000 person years of follow-up. A total of 377 working days were lost by 43 students due to the VZV infection, averaging 8.8 days per undergraduate. Total academic losses for the study cohort were; 205 lectures, 17 practicals, 13 dissection sessions, 11 tutorials, 124 days of clinical training and 107 days of professorial clinical appointments. According to their perception they lost 1,927 study hours due to the illness (Median 50 hours per undergraduate). CONCLUSIONS: The incidence of VZV infection among Sri Lankan medical undergraduates is very high and the impact of this infection on academic activities causes severe disruption of their undergraduate life. VZV immunization for susceptible new entrant medical undergraduates is recommended.

Erector spinae plane and intra thecal opioid (ESPITO) analgesia in radical nephrectomy utilising a rooftop incision: novel alternative to thoracic epidural analgesia and systemic morphine: a case series.

Background Open radical nephrectomy and inferior vena cava exploration through a roof top incision involves significant peri-operative morbidity including severe postoperative pain. Although thoracic epidural analgesia provides excellent pain relief, recent trends suggest search for effective alternatives. Systemic morphine is often used as an alternative analgesic technique. However, it does not provide dynamic analgesia and can often impede recovery in patients undergoing major surgery on the abdomen. The authors present the first report of a novel analgesic regimen in this cohort with good outcomes. Methods Five patients undergoing open radical nephrectomy and inferior vena cava exploration received erector spinae plane infusion and intra thecal opioid analgesia at a tertiary care university teaching hospital. Outcomes included dynamic analgesia, length of hospital stay and complications Results Five adult patients undergoing major upper abdominal surgery, who refused thoracic epidural analgesia, received erector spinae plane infusion and intrathecal opioid analgesia. Patients reported effective dynamic analgesia, minimal use of rescue analgesia, early ambulation and enhanced recovery. Conclusion The novel regimen that avoids both epidural analgesia and systemic morphine can be an option in enabling enhanced recovery in this cohort.

Disease Burden Assessment Beyond In-patient Data: A Morbidity Profile Assessment of Outpatients.

BACKGROUND: Global disease burden estimates often lack real data on morbidities, especially from patients treated in Outpatient Department (OPD). In Sri Lanka, around 40 million visits are made annually to the OPDs in government hospitals and we conducted a preliminary study to assess the morbidity profile of these OPD patients. METHODS: Patients attending the OPD, in teaching hospital Peradeniya, Sri Lanka, was recruited into the study using systematic random sampling procedure. A self-administered, structured questionnaire was used to collect data. Investigators explained the study to patients and data collection was completed before seeing the physician. Self-reported presenting complain was used to analyze the morbidity profile of the patients. RESULTS: The study sample consisted of 1 439 patients (male - 515, female - 924). The mean age of the study sample was 40 years (SD = 19 years). The mean age of the females were statistically significantly higher than that of the males (t = 4.03, P<0.001). Housewives constituted the major occupational group (52%) followed by students (15.9%). The most common presenting complains reported were body aches and pains (15.6%), cough and cold (10.5%), and abdominal pain (8.5%). Leading cause of hospital visit among different demographic categories showed statistically significant variations. CONCLUSIONS: The morbidity pattern observed in this patient population was not previously reported. OPD surveillance should be established to understand the changing pattern of minor ailments which might have a huge impact on health of the public.