Ganglion Impar Block For Chronic Coccydynia.

BACKGROUND: Coccydynia is also known as coccygodynia or coccygeal neuralgia. Coccyx is a triangular bone located within the vertebral column. The cause of coccydynia is unknown in the literature; however, it is found to be common among obese individuals, particularly females. The probability of women having coccydynia is five times higher than among men, which may result from larger pressure during pregnancy and child delivery. It is treated well with ganglion impar block. The aim of our study was to assess pain relief after Ganglion Impair Block with subsequent improvement in quality of life. METHODS: A single-arm study was done in the department of Pain Medicine, Fauji Foundation Hospital, Rawalpindi from July 2021 to June 2022. A total of 50 patients with ≥3 months' coccygeal pain of either gender aged between 20-60 years unresponsive to analgesics & anti-inflammatory medications with no laboratory abnormalities were included. Fluoroscopic guided trans-sacro­coccygeal ganglion impair block was done with alcohol neurolysis. The patients were observed for 1 hour in the recovery room to record post-intervention complications that may occur like hypotension, bradycardia, signs, and symptoms of cardiotoxicity or neurotoxicity etc. and evaluated for pain scores on the basis of the numeric rating scale (NRS). Data collected was analyzed using the statistical package for social scientists (SPSS) version 21. The quantitative data, i.e., age and NRS score were analyzed using mean and standard deviation and compared between pre and post-intervention periods. RESULTS: The data from 50 patients who completed the follow-up period were used for analysis. The average age of the patients was 42.9±8.39 years, with a range of 38-60 years. Based on the data obtained, 30% of the patients experienced trauma (that is falling on the coccyx region). The mean score from NRS before intervention was 7.80±0.16 which decreased to 0.96±0.35, respectively, and this difference was statistically significant (p-value, <0.001). CONCLUSIONS: Ganglion Impar neurolysis is highly effective in the treatment of chronic coccydynia.

General Anaesthesia Versus Regional Anaesthesia For Lumbar Laminectomy: A Review Of The Modern Literature.

BACKGROUND: Lumbar spine surgery can be performed using different anaesthetic techniques such as general endotracheal anaesthesia (GA) or spinal-based regional anaesthesia (RA). Few of the studies have been done to compare the outcomes of spinal anaesthesia versus general anaesthesia for lumbar laminectomies as both having some advantages as well as disadvantages but still it is controversial. The objective of current study is to make a comprehensive review of literature for comparing the outcomes of lumbar laminectomy performed under general anaesthesia versus spinal anaesthesia. METHODS: Literature search was performed by using PubMed, Google scholar and bibliography of related articles. To compare groups of general anaesthesia versus spinal anaesthesia, the variables focused were mean heart rate (HR), mean arterial pressure (MAP), blood loss during surgery, duration of surgery, post-operative anaesthesia care unit (PACU) time, postoperative narcotic use/pain scale, post-operative urinary retention, and post-operative nausea/vomiting. RESULTS: Data of eleven studies were presented in current article, of these five were randomized controlled trials, three case-controls and four were retrospective cohort studies. 5/8 studies reported that SA group having more hemodynamic stability with postoperative outcomes as compared to GA. Likewise, majority of reviewed studies (7/8) reported better pain control or decreased requirement of analgesics in SA group. Additionally, more than half of the reviewed studies (5/8) reported lower incidence of postoperative nausea and vomiting among patients of SA group.. CONCLUSIONS: The current study concluded that SA has better outcomes than GA in terms of hemodynamic stability and decrease postoperative adverse effects. So special attention should be paid for SA as an alternative to GA for lumbar laminectomy.

Surgical Attitudes And Preferences Regarding Choice Of Anaesthesia Amongst Orthopaedic Surgeons.

BACKGROUND: Regional anaesthesia is choice of anaesthesia for orthopaedic surgery due to lower side effects such as nausea, vomiting, postoperative pain and early mobilization. Despite of this, some orthopaedic patients refuse this modality. This study was conducted to interrogate the surgeons about their choice of anaesthesia in order to gain some insights into the concerns of surgeons and to change their minds and choose a safer mode of anaesthesia. The aim of the study was to assess the surgeons' fears and their perception about regional anaesthesia. METHODS: After institutional approval, thirty surgeons from three different tertiary care hospitals were interviewed. They were asked questions as per the questionnaire to choose choice of anaesthesia for their patients. RESULTS: After regional anaesthesia, 27.6% of respondents were concerned about paralysis and neurological disorders, 34.5% about seeing and hearing whatever is happening in theatre, 17.2% about perioperative pain, 24.1% about backache and 24.1% about delayed discharge. The most important reason to change their mind was the reassurance that the complications are not as frequently as they thought their patient would receive after a block. CONCLUSIONS: Due to the lack of information on regional anaesthesia and the risks of general anaesthesia, orthopaedic surgeons' fears and conceptions about regional anaesthesia are distorted. Anaesthesiologists should be aware of the concerns of the surgeons as well as the patients and should be willing to discuss the concerns with them and suggest the safest way to receive anaesthesia with evidence-based data.

Effect Of Dexamethasone Versus Placebo For Improved Recovery In Patients Undergoing Anaesthetic Interventions For General Surgical Procedures.

BACKGROUND: Endotracheal intubation is one of the basic prerequisites of general anaesthesia. Recovery of patients is delayed due to the development of post-operative nausea, vomiting, sore throat and shivering. This study was conducted to determine role of dexamethasone for improved recovery of patients. METHODS: This randomized controlled trial was performed in the Department of Anaesthesia, Ayub Teaching Hospital, Abbottabad from June to November 2018. One hundred and twenty-two consenting patients of both genders, aged between 18-60 years, American Society of Anaesthesiologists (ASA) I and II, scheduled for general surgeries of 60-180 minutes duration under general anaesthesia were included. Patients with long duration surgeries, anticipated difficult airways, nasogastric tube in situ, upper respiratory tract infections, on steroid therapy and critically ill and emergency surgeries were excluded. They were randomly allocated into two groups by lottery method as dexamethasone (group A, n=61) or Placebo (group B, n=61). Postoperative nausea, vomiting, sore throat was observed at 2, 12 and 24 hours, shivering was observed at 2 hours only and patient satisfaction at 24 hours post-operatively. RESULTS: Group A patients had statistically proven better outcomes at 2, 12 and 24 hours for post-operative sore throat, nausea and vomiting, shivering was controlled in 24.5% p-value (0.006). Patient satisfaction was found in 83.6% of group A patients.. CONCLUSIONS: Thus, dexamethasone is effective drug for prevention of postoperative nausea, vomiting, sore throat and shivering in general surgical procedures thus improving patient satisfaction and their early discharge.

Life Threatening Anaphylaxis With Co-Amoxiclav Despite Having A Previous Tolerant Exposure To The Antibiotic.

Co-amoxiclav is used as a routine prophylactic antibiotic in surgical procedures. We present a case of 61 years old lady came to outpatient clinic with a diagnosis of right sided lower alveolar tumour. A plan was made to proceed with a Right Marginal Mandibulectomy. She received Co amoxiclav as prophylactic antibiotic and was clinically uneventful. On further questioning there were many different occasions on which the patient had oral co amoxiclav with no complications or side effects. No known drug allergies or otherwise were documented. As a part of surgical antibiotic prophylaxis, Co amoxiclav 1.2 gm was given to patient at the time of induction. After the antibiotic administration patient started having bronchospasm with increased airway pressures and severe hypotension indicating anaphylactic reaction. The patient was resuscitated, recovered from the anaphylactic shock successfully and provided extended recovery in post anaesthesia care unit followed by High Dependency Unit for overnight monitoring. Every centre or ward that administers injectable antibiotics have to have a standard protocol for the management of allergy reactions. A timely fashion is mandatory to make the best use of the drugs available and emergency gadget ought to be in vicinity in case this type of state of affairs rise up.

Coeliac Plexus Neurolysis For Pancreatic Cancer Patients; Retrospective Analysis Of Shaukat Khanum Memorial Cancer Hospital & Research Centre Experience.

BACKGROUND: Among all the abdominal cancers, pancreatic cancer is the second most common one. Majority of the patients present with an excruciating pain when they are diagnosed with the disease. Coeliac plexus neurolysis (CPN) is a procedure that can control the pain in pancreatic cancer while precluding further consumption of analgesics in higher doses and quantity. The procedure of neurolysis is performed by injecting phenol/alcohol into the coeliac plexus ganglionic neural network. There is a high proportion of pain relief with CPN in up to 80% of the patients. AIM: The aim of our study is to assess the pain relief after CPN, reduction in analgesics consumption and evaluation of patient satisfaction post procedure. METHODS: A cross sectional study was done and we collected the retrospective data from December 2016 to November 2017. A total of 35 patients of either gender (male and female) were included in this study. Neurolysis was done with transcrural approach using 6% phenol. Follow up of patients was done after 1 and 4 weeks of the procedure. The patients were evaluated for pain scores on numeric rating scale (NRS), reduction in analgesia and patient satisfaction regarding the procedure and pain relief. The analysis was based on mean values. RESULTS: Total numbers of patients were 35. The mean age was 54.11±12.51 (SD) years with a male to female percentage of 31.43% and 68.57%. Follow up was done after 1 week and 4 weeks. Patients reported decrease in mean pain score (1 from 9 in Males and 0 from 9 in Females), reduction in analgesics (81.8% among Males and 18.2% among Females) and over all patient's satisfaction was (72.7% Males and 27.3% Females). CONCLUSIONS: It has been observed from the results that CPN works effectively for pancreatic cancer patients. There is a strong recommendation of neurolysis in patients with pancreatic cancer pain as it improves the pain scores, significant reduction in analgesia consumption with good patient satisfaction.

Massive Haemorrhage In Patient After Repair Of Post Esophagectomy Diaphragmatic Hernia And A Loading Dose Of Clopidogrel.

Postoperative diaphragmatic hernia (PDH) is an increasingly reported complication of esophageal cancer surgery. It occurs more frequently with minimally invasive techniques and very little is known about its pathogenesis. Currently, no consensus exists concerning preventive measures and its management. A 36 years old male underwent minimally invasive esophagectomy and presented with chest pain and dyspnoea in the emergency department 8 months after the procedure. He was started on acute coronary syndrome treatment protocol but was later diagnosed on CT scan to have diaphragmatic hernia through a defect in the oesophageal hiatus. As he was already loaded with dual anti platelet therapy it led to qualitative defect of the platelet which resulted in bleeding post procedure and the patient needed resuscitation with blood products. Dual anti-platelet therapy is an integral component of early management strategy in acute coronary syndrome. Chest X-ray was not helpful, but abdominal or chest computed tomography was useful for accurate diagnosis.

Incidence and management of rupture uterus in obstructed labour.

BACKGROUND: Obstructed labour with ruptured uterus is a serious obstetrical complication with a high incidence of maternal and foetal morbidity and mortality. This study was conducted to find out the incidence of uterine rupture particularly in the patients of obstructed labour (OL), foeto-maternal outcome of such patients, and its management. METHODS: This two year descriptive study was conducted in the Department of Obstetrics and Gynaecology Unit-I, at Muhammad Medical College Hospital from 1st January 2007 to 31st December 2008, on 40 diagnosed cases of OL. Patients were admitted through Casualty or were admitted in ward. Patients with previous caesarean section and myomectomy were excluded. RESULTS: Ruptured uterus was found in 8 out of 40 patients of obstructed labour, they were relatively elder and grand-multiparous. Mean age of the patients was 36.5 years, while parity ranged between 5 and 12. Only one (12.5%) patient was primigravida with mean gestational age of 39.15 weeks. Seven (87.5%) patients had abdominal pain and tenderness, 5 (62.5%) vaginal bleeding, and 2 (25%) had shock. All cases were immediately managed with fluid replacement, blood transfusion and surgery. Six (75%) cases were diagnosed as ruptured uterus on clinical features while 2 (25%) with incomplete rupture were diagnosed on caesarean section for obstructed labour. Foetal mortality rate was high (7, 87.5%); 5 (62.5%) were fresh stillbirth and 2 (12.5%) died in nursery. Only 1 (12.5%) baby survived. There was 1 maternal death due to puerperal sepsis. CONCLUSION: The incidence of rupture uterus in obstructed labour was 20%. Immediate intervention is important factor for successful management of uterine rupture.