Impact of Enhanced Recovery Protocols on Short-Term Outcomes in Esophagectomy: A Retrospective Cohort Study from Cancer Research Institute, Uttarakhand, India.

OBJECTIVE: Surgery for esophageal cancer is associated with high mortality and morbidity, especially in low and middle-income countries. The recent enhanced recovery after surgery guidelines for esophagectomy (2018) which attempt to reduce complications and length of stay (LOS) have rarely been validated in these settings. This study aimed to analyse the effect of this protocol on short-term outcomes in our subset of patients. METHODS: A retrospective review was conducted to investigate the outcomes of enhanced recovery protocol (ERP) compared to standard pre-protocol care (PP) in patients who underwent esophagectomy for cancer (31 in ERP vs 61 in PP group) at Cancer Research Institute, Uttarakhand, India. The main outcomes measured were 30-day mortality, morbidity and LOS. Risk assessment was stratified as per Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) systems while complications were classified as per the Clavien-Dindo scale. RESULTS: Preoperative clinical characteristics were similar between groups. Though the predicted POSSUM mortality and morbidity were significantly higher in the ERP group (p = 0.007), 30-day morbidity (19.35% vs 42.62%, p = 0.027) as well as median LOS (12 vs 15 days, p < 0.001) was significantly lower in ERP group. The PP group reported 4 deaths within 30 days as compared to none in the ERP group (p = 0.296). Furthermore, the ERP group reported lower occurrence of pulmonary complications (6.4%vs24.6%,p = 0.046), hemodynamic instability (0%vs14.75%,p = 0.026) as well as need for prolonged postoperative ventilation (> 24 h; 0% vs 11.48%, p = 0.004). Both minor and major complications as assessed by the Clavien-Dindo scale were lower in the group ERP though these differences were not statistically significant (0.059). CONCLUSIONS: Implementation of ERP improved short-term outcomes; hence can be strongly recommended in patients undergoing esophagectomy.

Ultrasound-guided erector spinae plane block versus port site infiltration for postoperative pain and quality of recovery in adult patients undergoing laparoscopic cholecystectomy: An assessor-blinded randomised controlled trial.

Background and Aim: Pain following laparoscopic cholecystectomy (LC) is common and results in poor quality of recovery. Our study aimed to compare the analgesic efficacy of port site local infiltration, novel erector spinae plane (ESP) block, and standard regimen in patients undergoing LC and its impact on functional recovery. Methods: After ethical approval and registering the trial, we randomly allocated 105 adult patients undergoing LC to three groups: Group I (n = 35), received multimodal analgesia; Group II (n = 35), received pre-incisional port site infiltration with 20 ml of 0.375% bupivacaine; and Group III (n = 35), preoperative bilateral ESP block with 20 ml of 0.375% bupivacaine bilaterally was administered. Pain severity, fentanyl consumption, and time to first rescue analgesia were recorded over 24 h. Quality of recovery (QoR-15) was assessed at baseline and 24 h postoperatively. Results: Pain in the first 6 h was lowest in the ESP group (P < 0.001). Although static pain in the infiltration group was comparable with that in the ESP group after 6 h (P > 0.05), dynamic pain was better in the ESP group till 20 h postoperatively (P < 0.05). Fentanyl consumption was significantly lower in the ESP group (P < 0.001). Global and sub-dimensional QoR-15 scores were significantly higher only in the ESP group at 24 h compared to the other two groups (P < 0.001). The infiltration group did better than the control group in terms of total opioid requirement (P < 0.001) and Visual Analogue Scale (VAS) score after 6 h (P < 0.001). Conclusion: ESP block provided lower postoperative pain scores with opioid-sparing and better quality of recovery in patients undergoing LC.

Outcome of perioperative 24-hour infusion of intravenous lignocaine on pain and QoR-15 scores after breast cancer surgery-A randomised controlled trial.

Background and Aims: Despite many analgesic modalities available, postoperative pain management after breast cancer surgery remains a challenge, which translates into poor quality of recovery, if untreated. Intravenous lignocaine with its anti-inflammatory, antihyperalgesic, and analgesic properties could provide a good option for these patients. The aim of this study was to evaluate the effect of intravenous lignocaine on postoperative pain relief and quality of recovery in patients undergoing surgery for breast cancer. Methods: In this prospective double-blind placebo-controlled randomised study, sixty-six patients undergoing breast cancer surgery were assigned 1:1 to placebo or intravenous lignocaine (Group L). Group L received an intravenous 1.5 mg/kg of lignocaine bolus at induction, followed by an intravenous infusion of 1 mg/kg/h for 24 hours intravenously, while the control group was given equal volume of normal saline. Pain scores, opioid utilisation, and quality of recovery (QoR-15) at 24 hours and on the day of suture removal were compared. Results: Statistically significant reduction was observed in both static (P = 0.01, 6 hours) and dynamic postoperative pain (P = 0.030, 24 hours), with consequential delay in the need for the first dose of opioid (P = 0.014) as well as decreased 24-hour postoperative opioid consumption (P < 0.001) and decreased post-operative nausea and vomiting (PONV) (P < 0.05) in the lignocaine group. Global QoR-15 was significantly better at 24 -hours in group L on postoperative day 1 (P < 0.001), albeit there was no significant difference at suture removal. No lignocaine related side effects were observed. Conclusion: Intravenous lignocaine can be safely used as an alternative perioperative non-opioid analgesic for early postoperative pain and recovery.

Myasthenia Gravis as a Cause of Failed Extubation Diagnosed by Diaphragmatic Ultrasound.

Myasthenia Gravis (MG) is an autoimmune disease of the neuromuscular junction which results in generalised weakness. Presentation varies and can often be delayed as the course is waxing and waning. We report the case of an elderly patient who was admitted with severe cholangitis. The patient required a general anaesthesia with intubation for a planned endoscopic retrograde cholangiopancreatogram (ERCP). She was extubated a few hours after the procedure in the intensive care unit (ICU). However, a few hours later, she required re-intubation for tiring out and a raised paCO2 level. When assessed by a diaphragmatic ultrasound, she was found to have severe weakness, and a provisional diagnosis of MG was made after other causes, such as sepsis, were ruled out. As a fast, inexpensive and non-invasive test, ultrasound offers many advantages and can also be used serially to assess recovery of a paralyzed diaphragm as well to achieve successful liberation from mechanical ventilation.

Prediction of endotracheal tube size in children by predicting subglottic diameter using ultrasonographic measurement versus traditional formulas.

BACKGROUND: Paediatric airway assessment remains the most challenging task before the anaesthesiologists. Recent advancement in ultrasonography techniques should now allow for accurate and descriptive evaluation of paediatric airway. To compare calculated external diameters of the endotracheal tube from physical indices of traditional formulas and predetermined by ultrasound. MATERIALS AND METHODS: 100 subjects of either sex between 12-60 months of age, undergoing various elective surgeries under general anaesthesia requiring endotracheal intubation were enrolled in the study. The transverse diameter was measured at the level of cricoids cartilage by ultrasonography. The tracheal tube was considered best fit if air leak was satisfactory at 15-20 cm H2O of airway pressure. The obtained values were compared with the values of endotracheal tube size calculated by various age, height, weight based formulas and diameter of right and left little finger. The correlation of size of Endotracheal tube by different modalities was done and Pearson's correlation coefficient was obtained. RESULTS: According to Pearson's correlation there was a moderate correlation of best fit Endotracheal tube with endotracheal tube size by age based formula (r = 0.743), body length based formula (r = 0.683), right little finger based formula (r = 0.587), left little finger based formula (r = 0.587) and multivariate formula (r = 0.741). There was a strong correlation with ultrasonography (r = 0.943). CONCLUSION: Ultrasonography is a reliable method of estimation of subglottic diameter and for prediction of endotracheal tube size in children.

Improved electroporation-mediated non-integrative transformation of Thermomyces lanuginosus.

The development of an efficient fungal expression system for recombinant proteins requires an improved transformation system for the host organism. We report a facile, efficient and highly reproducible electroporation-mediated transformation system for Thermomyces lanuginosus with a transformation efficiency of 1.27 x 10(3) transformants/microg DNA. Conidia of T. lanuginosus were stably transformed to hygromycin B resistance using the pBC-hygro plasmid construct. Optimal electroporation conditions for maximum transformation of 10(8) conidia ml(-1) in 1.2 M sorbitol buffer (15 mM DTT, 5% DMSO) were a field strength of 5.5 kV/cm for 10 ms and a DNA concentration of 0.5 microg microl(-1). Transformants were recovered in prewarmed potato dextrose broth supplemented with 1.2 M sorbitol for 1-2 h at 50 degrees C. The presence of the hygromycin B phosphotransferase (hph) gene and non-integrative transformation was confirmed by PCR, Southern hybridization analysis and plasmid recovery. Transformants exhibited altered phenotype with reduced pigmentation and transformants were found to be mitotically stable after 15 sequential transfers on nonselective media without selective pressure.