Analgesic Efficacy of Fascia Iliaca Compartment Block for Positioning During Spinal Anesthesia in Patients with Femur Fractures.

Background Positioning patients with femur fractures for spinal anesthesia is associated with excruciating pain. Fascia iliaca compartment block has the potential to block all nerves supplying the femur and therefore may provide effective analgesia during positioning these patients for spinal anesthesia. Objective To assess the analgesic efficacy of Fascia iliaca compartment block, during positioning patients with femur fracture for spinal anesthesia. We also assessed the duration of analgesia and the requirement for rescue analgesics in the postoperative period. Method Seventy adult patients with fracture femurs were randomly divided into two equal groups (A and B). Patients in both groups received fentanyl one mcg/kg intravenously, 20 minutes before positioning them for spinal anesthesia. Patients of group B additionally, received ultrasound-guided Fascia iliaca compartment block with 40 ml of 0.25% Ropivacaine, immediately after intravenous fentanyl. Numerical rating score (0-10) was used for the assessment of pain at five, 10, and 20 minutes after the block and immediately after positioning patients for spinal anesthesia. Result Immediately after positioning patients for spinal anesthesia, the numerical rating score of pain was 5.06±1.5 in group A and 2.49±1.2 in group B (p<0.001). The duration of analgesia was 799.7±62.1 minutes in group B and 314.65±118.9 minutes in group A (p<0.001). One (2.8%) patient of group B and 18(51.4%) patients of group A required rescue analgesics within four to twelve hours in the postoperative period (p=0.001). In group A, seven patients were satisfied with the analgesia technique while in group B, 17 were satisfied and eight patients were strongly satisfied (p<0.001). Conclusion Ultrasound-guided Fascia iliaca compartment block is effective in reducing pain during positioning patients with femur fractures for spinal anesthesia. Patients receiving this block had a prolonged duration of analgesia, required lesser analgesics, and were more satisfied in the postoperative period as compared to patients not receiving the block.

Intraoperative Infusion of Magnesium Sulphate does not Reduce Laryngospasm and Agitation during Emergence from Anaesthesia in Children.

Background Laryngospasm and agitation during emergence from general anaesthesia are frequent in children. Magnesium sulphate may have the potential of reducing both of these adverse events. In addition, magnesium has analgesic and anaesthetic properties. Objective To find out the effectiveness of magnesium sulphate in reducing the occurrence of emergence laryngospasm and agitation and other adverse events if any in children. Method Randomized, placebo controlled study was conducted at a tertiary care hospital in 132 children, aged 3-12 years undergoing general anaesthesia for hernia and hydrocele surgery. Children with American Society of Anaesthesiologist Physical Status > II were excluded. After insertion of laryngeal mask airway, 20 ml of either magnesium sulphate 15 mg/kg (Group M) or normal saline (Group N) was infused at the rate of 1 ml/min. The severity of laryngospasm and agitation was assessed. We also noted other adverse events, if occurred. Result Laryngospasm occurred in 7(10.6%) patients of group M and in 10(15.1%) patients of group N(p=0.40). While 14(10.6%) patients developed laryngospasm immediately after removal of LMA, only 3(2.2%) patients developed it in the post anaesthetic care unit. Two (3.0%) patients of group M and four patients (6.0%) of group N were agitated (p=0.40). Three (4.5%) patients of group M and 14(21.2%) patients of group N coughed during emergence (p=0.004). Conclusion Intraoperative infusion of 15 mg/kg magnesium sulphate, does not reduce the occurrence of emergence laryngospasm and agitation in children. However, it significantly reduce emergence cough.

Whole blood transcriptome analysis reveals footprints of cattle adaptation to sub-arctic conditions.

Indigenous cattle breeds in northern Eurasia have adapted to harsh climate conditions. The local breeds are important genetic resources with cultural and historical heritages, and therefore, their preservation and genetic characterization are important. In this study, we profiled the whole-blood transcriptome of two native breeds (Northern Finncattle and Yakutian cattle) and one commercial breed (Holstein) using high-throughput RNA sequencing. More than 15 000 genes were identified, of which two, 89 and 162 genes were significantly upregulated exclusively in Northern Finncattle, Yakutian cattle and Holstein cattle respectively. The functional classification of these significantly differentially expressed genes identified several biological processes and pathways related to signalling mechanisms, cell differentiation and host-pathogen interactions that, in general, point towards immunity and disease resistance mechanisms. The gene expression pattern observed in Northern Finncattle was more similar to that of Yakutian cattle, despite sharing similar living conditions with the Holstein cattle included in our study. In conclusion, our study identified unique biological processes in these breeds that may have helped them to adapt and survive in northern and sub-arctic environments.

Implications of Subarchnoid Block in Senile Kyphosis.

Since the literature related to safety or efficacy of placing spinal blocks in patients with kyphosis is lacking, we aim to discuss about the anaesthesia implications of spinal anaesthesia in senile kyphosis. We successfully administered spinal anesthesia in three elderly patients with predominant kyphotic deformity with absent or mild scoliosis. The needle insertion attempts did not exceed two and a smaller dose of anesthetic was sufficient. While choosing spinal anaesthesia in patients with kyphosis, a risk benefit analysis needs to be performed based on the co-presence of scoliosis and its severity, desired level of anesthesia, and associated or coexisting systemic illness.

Adverse Events in Children Receiving General Anaesthesia with Laryngeal Mask Airway Insertion.

INTRODUCTION: Perioperative adverse events are more common in children compared to adult population. Reporting an adverse event proves effective in identifying problems and helps in prevention and early management. Our objective was to identify the types, incidence, and the time of occurrence of perioperative adverse event. We also aimed to find out whether the occurrence of the types of adverse events differ in children below and above five years. METHODS: This was a prospective study in 242, ASA Physical Status I and II children aged day one to 14 years, receiving general anesthesia with laryngeal mask airway for various elective surgeries. Adverse events observed in the perioperative period were recorded. RESULTS: Adverse events related to respiratory system (n=26, 55%) were the most common followed by cardiovascular system (n= 14, 30%). Adverse events were observed in 24(10%) children in the operating room and in 20 (8%) children in the post anaesthesia care unit. In the operating room, majority (14 of 27, 52%) of the events occurred immediately after removal of laryngeal mask airway. Respiratory events were more common in children below five years (p=0.007), whereas cardiac events were more common in children above five years (p=0.02). CONCLUSIONS: The commonest adverse event in children is related to respiratory system. Adverse events occur more frequently in the operating room, mostly immediately after removal of laryngeal mask airway. Respiratory events are more frequent in children below five years whereas cardiac events are more frequent in children above five years.

Successful intubation with McCoy laryngoscope in a patient with ankylosing spondylitis.

Involvement of cervical spine in ankylosing spondylitis limits neck movement resulting in difficult intubation. We report a case of 45-yr-old lady of ankylosing spondylitis with restricted neck movement planned for emergency laparotomy. Grade 3 Cormack and Lehane laryngoscopic view was observed with Macintosh laryngoscope and gum elastic bougie could not be negotiated. At second attempt with McCoy blade, the posterior commissure of the vocal cord could be visualized and intubation was successful. Thus, in absence of flexible laryngoscopes and when awake intubation is not feasible, McCoy blade should be considered an alternative than Macintosh blade to attempt intubation in patients of ankylosing spondylitis with restricted neck movement.

Large versus Small Dose Magnesium Sulfate Infusion in Tetanus.

INTRODUCTION: Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms. METHODS: Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h(-1)) than group 2 (n=5) (1.5 to 2 g.h(-1)). RESULTS: The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d(-1)) than group 2 (n=3) (106±9 mg.d(-1)) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO(4) for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d(-1)) of infusion in group 2 (n=4) but not in group 1 patients (n=4). CONCLUSIONS: The larger dose of MgSO(4) infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose.

Preinduction incentive spirometry versus deep breathing to improve apnea tolerance during induction of anesthesia in patients of abdominal sepsis: A randomized trial.

BACKGROUND: Abdominal sepsis is associated with varied degree of hypoxemia and atelactasis in the lung and can enhance the onset of desaturation of arterial blood during apnea. AIMS: This study looked at methods to improve safety margin of apnea during induction of anesthesia in these high-risk patients. SETTINGS AND DESIGN: It was a randomized, single blind study on adult patients presenting for emergency laparotomy due to peritonitis in a university teaching hospital setting. MATERIALS AND METHODS: In group 1 (IS) (n = 32), three sessions of incentive spirometry (IS) were performed within one hour before induction of anesthesia. In group 2 (DB) (n = 34), patients were subjected to deep breathing sessions in a similar manner. All patients received preoxygenation (100%) by mask for 3 min, followed by rapid-sequence induction of anesthesia using fentanyl, thiopental, and suxamethonium and endotracheal intubation. Patients were subjected to a period of apnea by keeping the end of the endotracheal tube open to air till they developed 95% hemoglobin saturation (SpO 2) by pulse oxymetry. Positive pressure ventilation was resumed at the end. We observed for hemodynamic changes, apnea time, and SpO 2 (100%) recovery time on resuming ventilation. Arterial blood gas samples were taken before intervention, after IS or DB, after preoxygenation, and at the end of apnea. STATISTICAL ANALYSIS USED: One-way analysis of variance (ANOVA), X 2 test, Kaplan-Meier graph, and log-rank tests were applied to compare the two study groups. RESULTS: Oxygenation level in group 1 (265 ± 76.7 mmHg) patients was significantly (P < 0.001) higher than in group 2 (221 ± 61.8 mmHg)at the end of preoxygenation. The apnea time (median: lower bound - upper bound Confidence Interval apnea time) (272:240-279 s) in group 1 (IS) patients was significantly higher P < 0.05) than in group 2 (180:163-209 s) patients. Saturation recovery time (35:34-46 s) in group 1 (IS) patients was also quicker than in group 2 patients (48:44-58 s). CONCLUSIONS: IS in the preoperative period is superior to deep breathing sessions for improving apnea tolerance during induction of anesthesia in abdominal sepsis patients.

Analgesic effects of intrathecal tramadol in patients undergoing caesarean section: a randomised, double-blind study.

BACKGROUND: Intrathecal tramadol combined with local anaesthetics has been used for postoperative analgesia following lower abdominal and perineal surgery. The present study evaluated the effect of intrathecal tramadol on spinal block characteristics and neonatal outcome after elective caesarean section. METHODS: Eighty full-term parturients scheduled for elective caesarean section were randomly divided into two groups. In the fentanyl group, patients received intrathecal 0.5% bupivacaine 10 mg with fentanyl 10 µg; in the tramadol group, patients were given the same dose of bupivacaine with tramadol 10 mg. Sensory and motor block characteristics, duration of postoperative analgesia, maternal side effects, and neonatal outcome were compared. RESULTS: One patient in the tramadol group and two patients in the fentanyl group were excluded from data analysis. Median [interquartile range] duration of postoperative analgesia in the tramadol and the fentanyl groups was 300 [240-360] min and 260 [233-300] min respectively (P = 0.02). The incidence of shivering was lower in patients who received tramadol (5%) than those who had fentanyl (32%) (P = 0.003). Apgar scores, umbilical cord acid-base measurement and neurologic and adaptive capacity scores were comparable between the two groups. CONCLUSION: Compared to intrathecal fentanyl 10 µg, tramadol 10 mg, as an adjunct to bupivacaine for subarachnoid block for caesarean section, showed a longer duration of analgesia with a reduced incidence of shivering.

Postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block: a randomized study of dexamethasone prophylaxis.

BACKGROUND: Postoperative nausea and vomiting is a common distressing problem in patients undergoing gynaecological surgery under anaesthesia including central neuraxial blockade, which requires frequent medical interventions. OBJECTIVES: We aimed to find out the antiemetic effect of prophylactic dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block. Influences of dexamethasone on patient satisfaction and postoperative analgesia were also observed as secondary objectives. METHODS: This was a prospective, randomized, double blind, placebo controlled study conducted in BPKIHS, from January 2009 to April 2009. This study involved 80 American Society of Anaesthesiologist Physical Status I and II patients undergoing total abdominal hysterectomy under subarachnoid block. Patients were divided into two groups of 40 each to receive either 4 mg of dexamethasone (group D) or normal saline (group N) in volume of 2 ml intravenously 1 hour prior to subarachnoid block. Surgery was allowed to start with block height of at least T8 dermatome. Intraoperative and postoperative nausea and vomiting was observed using nausea and vomiting scale every 4 hour for 24 hours. RESULTS: Seven (17.4%) patients in group D and 11 (27.5%) patients in group N had nausea and vomiting in the intraoperative period (P=0.284). Sixteen (40%) patients in group D experienced nausea and vomiting in the postoperative period as compared to 27 (67.5%) in group N (P =0.0136). Accordingly, the mean requirement of rescue antiemetic was less in group D compared to Group N (P=0.042). Further, only 15 (37.5%) patients in group D required postoperative supplemental analgesic as compared to 23 (57.5%) in group N (P=0.058). After 24 hrs of surgery, 26 (65%) patients expressed satisfaction in group D as compared to 16 (40.0%) in group N (P =0.025). CONCLUSIONS: Use of dexamethasone prior to subarachnoid block in patients undergoing total abdominal hysterectomy significantly reduces the incidence of nausea and vomiting and the requirement of antiemetic in the postoperative period, with better patient satisfaction.

Ambiguous phorate granules for sesame seeds linked to accidental organophosphate fatal poisoning.

UNLABELLED: Ingestion of organophosphate compound for suicidal attempt is a major health problem in developing countries. However, unintentional ingestion by an adult is rare. An 80-year-old lady and her 30-year-old granddaughter consumed phorate (organophosphate) granules thinking it to be the seeds of sesame. After grinding the granules and mixing with pickle, they consumed the preparation with rice. The granddaughter was brought dead at emergency department and the older lady after resuscitation shifted to intensive care unit. She was extubated on 17th day and discharged on 23rd day. Pesticide formulation resembling any edible items must be withdrawn from the market at the earliest. Stringent regulation on vendors, apparent formulation or packaging and education about the hazards of these compounds can prevent this type of unintentional poisoning. KEYWORDS: Ambiguous, organophosphate, phorate, sesame seeds, unintentional poisoning.

The effect of height and weight adjusted dose of intrathecal hyperbaric bupivacaine for elective caesarean section.

INTRODUCTION: The study compared spinal anesthesia using intrathecal hyperbaric bupivacaine between height and weight adjusted dose and fixed dose during caesarean section. METHODS: A hundred parturients, who had given their consent and were scheduled for elective caesarean section under spinal anesthesia, were randomly assigned into two groups. We adjusted the intrathecal dose of heavy bupivacaine (0.5%) according to the height and weight of patients (Group AD) from Harten's dose chart developed from the Caucasian parturients and the fixed dose (2.2 ml) was used in Group FD patients. Keeping the observer blinded to the study groups, the onset time to sensory block up to T5, haemodynamic changes, side effects, and fetal outcome were observed. RESULTS: The median onset time of spinal block in Group FD was faster than in Group AD (6 min vs. 4 min; p = 0.01). The spinal block level extended above T3 level in a significantly (p < 0.05) larger number of patients 12 (24%) in Group FD than in one (2%) patient in Group AD. A significantly (p < 0.05) larger number of patients, 32, (64%) in Group FD had hypotension than in 15 (30%) patients in Group AD. The lowest recorded SAP (101 +/- 6 mm Hg) in Group AD was higher than in Group FD (96 +/- 6.7 mm Hg). Nausea and vomiting were more pronounced in Group FD patients. CONCLUSIONS: The bupivacaine dose was significantly reduced on its dose adjustment for the body weight and height of patients for cesearean section. This adjusted-dose use suitably restricted spinal block level for cesarean section with a distinct advantage of less hypotension and with a similar neonatal outcome as fixed compared with the dose use.

Estimation of serum uric acid in cases of hyperuricaemia and gout.

INTRODUCTION: Gout is crystal deposit arthritis and is an ancient disease. The biologic precursor to gout is hyperuricaemia. The prevalence of hyperuricaemia and gout has an increasing trend all over the world including the developing countries. The purpose of this study is to estimate serum uric acid level in hyperuricaemic and gout patients attending a medical college hospital. METHODS: A consecutive 150 hyperuricaemics and 150 gout patients attending Tribhuwan University Teaching Hospital from June to September 2007 were included in this study. The serum uric acid level was measured by the enzymatic (PAP- Uricase) method. The patients with acute gout were interviewed and relevant information was obtained. RESULTS: Males comprised 84% of gout cases. Hyperuricaemia was common in both sexes. The mean age for gout was 47.49 and 56.65 years in males and females respectively. The mean age for the first gout attack was 42.1 +/- 14.0 years. Family history was positive in 22% of cases. The overall mean serum uric acid level in hyperuricaemics was 7.2 +/- 0.7 mg/dL and 8.4 +/- 1.1 mg/dL in acute gout (p 0.0001). The mean serum uric acid level was significantly (p 0.0001) high among males both at the asymptomatic phase and at acute gout. Gout was more common in non-vegetarians (95%) and alcoholics (65.3%). Serum uric acid level was inversely related with the amount of daily water intake (p 0.0001). CONCLUSIONS: Serum uric acid level is significantly high among the male gouty arthritic patients. However, it is also high among asymptomatic hyperuricaemic cases of both sexes.

Anaesthetic management of tracheal agenesis.

Tracheal agenesis is a rare but uniformly fatal congenital condition that obstetricians, neonatologists or anaesthesiologists may encounter as an unexpected emergency. Ventilation with bag and mask or through an endotracheal tube placed in the oesophagus may be the only options left for immediate survival and evaluation. Ventilation and maintenance of adequate oxygenation can be difficult during surgical interventions. We report a case of neonate in which ventilation and anaesthesia were maintained through an endotracheal tube in the oesophagus and frequent episodes of drop in oxygen saturation were observed during surgery. Anaesthetic management, airway and other issues are discussed.

The efficacy and safety of low dose epidural butorphanol on postoperative analgesia following cesarean delivery.

Butorphanol is considered an effective and safe analgesic after cesarean delivery but is associated with profound dose-dependent sedation. Somnolence may cause hindrance in early mother-baby interaction. This study was designed to assess the analgesic efficacy and to monitor side-effects of low doses (0.5 mg and 0.75 mg) of epidural butorphanol with bupivacaine compared to bupivacaine alone in parturients following cesarean delivery. One hundred and twenty parturients (American Society of Anesthesiologists physical status 1 and 2) undergoing cesarean delivery were allocated into three groups: group 1 received epidural 0.125% bupivacaine while group 2 and 3 received an additional 0.5 mg and 0.75 mg butorphanol respectively. A combined spinal, epidural technique was used. Spinal anaesthesia was used for surgery. The epidural route was used for postoperative analgesia with the study drug. Onset, duration and quality of analgesia, lowest visual analogue scales (VAS) score, and side effects were noted. The onset and duration of analgesia in group 2 (4.1+/-2.6 min and 202.4+/-62.8 min) and group 3 (4.0+/-2.5 min and 192.3+/-69.1 min) were significantly different (P<0.01) from group 1 (6.6+/-2.7 min and 145.7+/-89.6 min). The quality of analgesia in terms of time to first independent movement and satisfactory VAS were statistically better (P<0.01) in group 2 (3.9+/-0.3 hour and 8.1+/-0.1 mm) and group 3 (3.8+/-0.4 hour and 8.1+/-0.9 mm) than in group 1 (5.2+/-0.4 hour and 6.3+/-1.3 mm). The incidence of sedation was 5% in all the three groups. A lower dose of epidural butorphanol with bupivacaine produces a significantly earlier onset, longer duration and better quality of analgesia than bupivacaine does.