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.

A case of antenatally undiagnosed laryngeal atresia with tracheo-esophageal fistula with airway obstruction at birth and its management.

Laryngeal atresia is a rare congenital anomaly that is usually diagnosed by antenatal ultrasound, however, if undiagnosed presents with desaturation after birth. A term neonate presented with airway obstruction after birth with multiple failed attempts at intubation and was rescued by proseal laryngeal mask airway (LMA). An esophagoscopy using an Ambuscope utilizing a modified connector assembly revealed an opening on the anterior wall of the esophagus with no esophageal atresia, leading to a diagnosis of H-type tracheo-esophageal fistula (TEF) with laryngeal atresia. The ability to ventilate the neonate via LMA with an absent glottic opening raised the possibility of TEF.

Quadratus lumborum block vs. transversus abdominis plane block in laparoscopic trans-abdominal pre-peritoneal repair of inguinal hernia in adults: A randomised controlled trial.

Background and Aims: Laparoscopic trans abdominal preperitoneal (TAPP) repair of hernia is one of the most commonly performed surgeries and may cause significant postoperative pain. Among different truncal block techniques, quadratus lumborum (QL) and transversus abdominis plane blocks (TAP) are used during this abdominal surgery. We aimed to investigate whether, bilateral QL block by trans-muscular approach provided better analgesia as compared to posterior TAP block in these patients. Methods: Forty adult patients with American Society of Anesthesiologists physical status I and II, undergoing inguinal hernia repair were randomized to receive either QL or TAP block, with 20 mL of 0.25% ropivacaine bilaterally. The primary objective of the study was to compare the total fentanyl consumption (in µg) within 24 hours postoperatively. The secondary objectives studied were dermatomal spread, quality of recovery at discharge and at 3 months postoperatively. Results: There was a significant reduction in total 24-hour fentanyl consumption (552 ± 229.56 vs 735.5 ± 264 µg, P =0.01) in the QL group, with longer duration of analgesia [282.5 ± 89.9 min group TAP vs. 354.8 ± 107 min QL, (mean difference -72.34,95% confidence interval -135.516 to -9.024), P =0.03], as compared to TAP group. At T8 and T9 dermatomes, greater proportion of patients in the QL group attained analgesia. Quality of Recovery at 24 hours and at 3 months of follow-up were comparable. Conclusion: QL block provided better perioperative analgesia than TAP block, in patients undergoing laparoscopic hernia repair. It also leads to greater dermatomal spread but without any decrease in the incidence of chronic pain at 3 months postoperatively.

Efficacy of Clonidine as an Adjuvant to Ropivacaine in Transversus Abdominis Plane Block in Adult Renal Transplant Recipients: A Double-blinded Randomized Controlled Trial.

Background and Aims: Transversus abdominis plane (TAP) block has been used to provide analgesia in renal transplant surgery with varying results. This study was designed to assess if the addition of clonidine in TAP block would decrease 24-h postoperative morphine consumption in adult renal transplant recipients. Materials and Methods: Forty adult patients undergoing renal transplantation under general anesthesia in a tertiary care hospital were randomized into either group RC (TAP block with 20 mL of 0.5% ropivacaine plus 2 µg.kg-1 clonidine) or group R (TAP block with 20 mL 0.5% ropivacaine) after induction of anesthesia. Postoperative analgesia was provided using patient-controlled morphine. The primary outcome was 24-h patient-controlled morphine consumption. The secondary outcomes were a) intraoperative hemodynamics, b) fentanyl and ephedrine requirement, c) postoperative pain using the Visual Analog Scale at 0, 2, 6, 12 and 24 hours, d) time to first postoperative analgesia, e) postoperative hemodynamics, and f) side effects. Results: There was no significant difference in postoperative morphine consumption between the groups (25 mg in group RC vs. 28.5 mg in group R) (median interquartile range) (P = 0.439). Postoperative pain scores were comparable between the groups. Intraoperatively, fewer patients required rescue fentanyl in group RC (7 patients) as compared to group R (17 patients) (P = 0.003). Significantly more patients in group RC required ephedrine boluses as compared to group R (9 patients in group RC vs. 2 in group R, P = 0.014). Conclusions: The addition of 2 µg.kg-1 clonidine to ropivacaine in TAP block did not reduce 24-h postoperative morphine consumption after renal transplantation. It reduced the need for intraoperative analgesics but increased the need for intraoperative ephedrine administration.

Role of serial lactate measurement to predict 28-day mortality in patients undergoing emergency laparotomy for perforation peritonitis: prospective observational study.

BACKGROUND: Serial lactate measurement is found to predict mortality in septic shock. Majority of patients with perforation peritonitis for emergency laparotomy are in sepsis and mortality rate is substantial. However, lactate dynamics has not been studied in this patient population. METHODS: After institutional ethics clearance and informed written consent, 113 patients with suspected or proven perforation peritonitis presenting for emergency laparotomy were recruited in this prospective observational trial. Baseline Mannheim peritonitis index (MPI), SOFA and APACHE II score were calculated. Lactate values were obtained at baseline, immediate and 24-h postoperative period. Primary outcome was 28-day mortality. RESULTS: Mortality was 15.04% at 28 days. Age, SOFA, qSOFA, APACHE, preoperative lactate, MPI and site of perforation were significantly different between survivors and non-survivors. Arterial lactate values at preoperative (cut off 2.75 mmol/L), immediate postoperative (cut off 2.8 mmol/L) and 24 h-postoperative period (cut off 2.45 mmol/L) independently predicted mortality at day 28. Combination of MPI and 24-h lactate value was best predictor of mortality with AUC 0.99. CONCLUSION: Preoperative, immediate postoperative and 24-h postoperative lactate value independently predict 28-day mortality in perforation peritonitis patients undergoing emergency laparotomy. Combination of MPI and 24-h lactate value is the most accurate predictor of mortality. TRIAL REGISTRATION: Clinical Trial Registry of India - CTRI/2018/01/011103.

Comparison of Efficacy of Oral versus Regional Clonidine for Postoperative Analgesia following Ilioinguinal/iliohypogastric Block in Children: A Prospective, Randomized, Double-blinded, Placebo-controlled Study.

BACKGROUND: Clonidine improves quality and prolongs the duration of analgesia in ilioinguinal/iliohypogastric nerve block when given along with local anesthetic and as well as premedication. The objective of this study was to compare the efficacy of oral and regional clonidine for postoperative analgesia in pediatric population after ilioinguinal/iliohypogastric block. MATERIALS AND METHODS: Sixty children aged between 1 and 8 years scheduled for elective hernia surgery were randomly allocated to three groups. Group I received oral midazolam and regional bupivacaine, Group II received oral midazolam with oral clonidine and regional bupivacaine, and Group III received oral midazolam and regional clonidine with bupivacaine. Preoperative sedation and separation score and postoperative duration and quality of analgesia, analgesic need, sedation score, and side effects of clonidine were assessed up to 6 h, postoperatively. RESULTS: Duration of analgesia was prolonged in Group II (2.83 ± 2.01 h) and Group III (4.43 ± 2.29 h) compared to Group I (3.98 ± 2.58 h), but the difference was not statistically significant (P = 0.161). Analgesic requirement was comparable between all the groups intraoperatively (P = 0.708) and postoperatively (P = 0.644). Group II had better parental separation (P < 0.001) and sedation score (P < 0.001) compared to Group I and III. Postoperatively, patients of Group II and III were more sedated compared to Group I up to 120 min. Adverse effects of clonidine were equally distributed in all the groups. CONCLUSION: Both oral and regional clonidine was equally efficacious in prolongation of duration and quality of analgesia. Oral clonidine produces better preoperative sedation and parenteral separation which is an added advantage in pediatric population.

Effect of dexmedetomidine as an adjuvant to bupivacaine in femoral nerve block for perioperative analgesia in patients undergoing total knee replacement arthroplasty: A dose-response study.

CONTEXT: Dexmedetomidine is being increasingly used in nerve blocks. However, there are only a few dose determination studies. AIMS: To compare two doses of dexmedetomidine, in femoral nerve block, for postoperative analgesia after total knee arthroplasty (TKA). SETTINGS AND DESIGN: A prospective, randomized, controlled trial was conducted in the Department of Anesthesia at AIIMS, a Tertiary Care Hospital. MATERIALS AND METHODS: Sixty American Society of Anesthesiologists I-II patients undergoing TKA under subarachnoid block were randomized to three Groups A, B, and C. Control Group A received 20 ml (0.25%) of bupivacaine in femoral nerve block. Groups B and C received 1 and 2 µg/kg dexmedetomidine along with bupivacaine for the block, respectively. Outcomes measured were analgesic efficacy measured in terms of visual analog scale (VAS) score at rest and passive motion, duration of postoperative analgesia, and postoperative morphine consumption. Adverse effects of dexmedetomidine were also studied. STATISTICAL ANALYSIS USED: All qualitative data were analyzed using Chi-square test and VAS scores using Kruskal-Wallis test. Comparison of patient-controlled analgesia (PCA) morphine consumption and time to first use of PCA were done using ANOVA followed by Least Significant Difference test. A P < 0.05 was considered statistically significant. RESULTS: The VAS score at rest was significantly lower in Group C compared to Groups A and B (P < 0.05). There was no difference in VAS score at motion between Groups B and C. The mean duration of analgesia was significantly longer in Group C (6.66 h) compared to Groups A (4.55 h) and B (5.70 h). Postoperative mean morphine consumption was significantly lower in Group C (22.85 mg) compared to Group A (32.15 mg) but was comparable to Group B (27.05 mg). There was no significant difference in adverse effects between the groups. CONCLUSION: The use of dexmedetomidine at 2 µg/kg dose in femoral nerve block is superior to 1 µg/kg for providing analgesia after TKA, although its role in facilitating early ambulation needs further evaluation.

Efficacy of magnesium as an adjuvant to bupivacaine in 3-in-1 nerve block for arthroscopic anterior cruciate ligament repair.

BACKGROUND AND AIMS: Three-in-one and femoral nerve blocks are proven modalities for postoperative analgesia following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to evaluate the efficacy of magnesium (Mg) as an adjuvant to bupivacaine in 3-in-1 block for ACL reconstruction. METHODS: Sixty patients undergoing arthroscopic ACL reconstruction were randomly allocated to Group I (3-in-1 block with 30 ml of 0.25% bupivacaine preceded by 1.5 ml of intravenous [IV] saline), Group II (3-in-1 block with 30 ml of 0.25% bupivacaine preceded by 1.5 ml of solution containing 150 mg Mg IV) or Group III (3-in-1 block with 30 ml containing 0.25% bupivacaine and 150 mg of Mg as adjuvant preceded by 1.5 ml of IV saline). Post-operatively, patients received morphine when visual analogue scale (VAS) score was ≥4. Quantitative parameters were compared using one-way ANOVA and Kruskal-Wallis test and qualitative data were analysed using Chi-square test. RESULTS: Demographics, haemodynamic parameters, intra-operative fentanyl requirement, post-operative VAS scores and total morphine requirement were comparable between groups. Time to first analgesic requirement was significantly prolonged in Group III (789 ± 436) min compared to Group I (466 ± 290 min) and Group II (519 ± 274 min), (P = 0.02 and 0.05). Significantly less number of patients in Group III (1/20) received morphine in the first 6 h post-operatively, compared to Group I (8/20) and Group II (6/20) (P = 0.008 and 0.03). No side effects were observed. CONCLUSION: Mg as an adjuvant to bupivacaine in 3-in-1 block for ACL reconstruction significantly prolongs the time to first analgesic requirement and reduces the number of patients requiring morphine in the immediate post-operative period.

Comparison of dexamethasone and clonidine as an adjuvant to 1.5% lignocaine with adrenaline in infraclavicular brachial plexus block for upper limb surgeries.

BACKGROUND AND AIMS: The role of clonidine as an adjuvant to regional blocks to hasten the onset of the local anesthetics or prolong their duration of action is proven. The efficacy of dexamethasone compared to clonidine as an adjuvant is not known. We aimed to compare the efficacy of dexamethasone versus clonidine as an adjuvant to 1.5% lignocaine with adrenaline in infraclavicular brachial plexus block for upper limb surgeries. MATERIAL AND METHODS: Fifty three American Society of Anaesthesiologists-I and II patients aged 18-60 years scheduled for upper limb surgery were randomized to three groups to receive 1.5% lignocaine with 1:200,000 adrenaline and the study drugs. Group S (n = 13) received normal saline, group D (n = 20) received dexamethasone and group C (n = 20) received clonidine. The time to onset and peak effect, duration of the block (sensory and motor) and postoperative analgesia requirement were recorded. Chi-square and ANOVA test were used for categorical and continuous variables respectively and Bonferroni or post-hoc test for multiple comparisons. P < 0.05 was considered significant. RESULTS: The three groups were comparable in terms of time to onset and peak action of motor and sensory block, postoperative analgesic requirements and pain scores. 90% of the blocks were successful in group C compared to only 60% in group D (P = 0.028). The duration of sensory and motor block in group S, D and C were 217.73 ± 61.41 min, 335.83 ± 97.18 min and 304.72 ± 139.79 min and 205.91 ± 70.1 min, 289.58 ± 78.37 min and 232.5 ± 74.2 min respectively. There was significant prolongation of sensory and motor block in group D as compared to group S (P < 0.5). Time to first analgesic requirement was significantly more in groups C and D as compared with group S (P < 0.5). Clinically significant complications were absent. CONCLUSIONS: We conclude that clonidine is more efficacious than dexamethasone as an adjuvant to 1.5% lignocaine in brachial plexus blocks.

Anesthetic management of a 2-day-old with complete congenital heart block.

Maternal connective tissue disorders such as Systemic Lupus Erythematosus (most common), Sjogren's syndrome, mixed connective tissue disorders may lead to the rare condition of complete congenital heart block in the neonate. Rare fetal syndromes such as myocarditis, 18p syndrome, mucopolysaccharidoses and mitochondrial diseases are other causes. The mortality rate of this condition is inversely propotional to the age of presentation being 6 % in the neonatal age group. As the cardiac output in the neonate is heart rate dependent, it is crucial to maintain the heart rate in these patients. Pharamacological interventions with dopamine, isoprenaline, epinephrine and atropine are known for their variable response. Although permanent pacing is the most reliable mode of management, the access to it is often not readily available, especially in the developing countries. In such cases temporary pacing methods become lifesaving. Of all the modalities of temporary pacing (transcutaneous, transesophageal and transvenous) transcutaneous pacing is the most readily available and immediate mode. In this case report we present a two day old neonate with isolated complete congenital heart block and a resting heart rate of 50-55/min in immediate need of palliative surgery for trachea-esophageal fistula (TEF). With pharmacological intervention the heart rate could only be raised to 75-80/min. The surgery was successfully carried out using transcutaneous pacing to maintain a heart rate of 100/min.

Anaesthetic management for emergency caesarean section in a patient with an untreated recently diagnosed phaeochromocytoma.

Phaeochromocytoma is a rare cause of hypertension during pregnancy with potentially fatal consequences. If not detected and treated early in pregnancy, it is catastrophic for both the mother and the baby. Management requires close co-ordination between the obstetrician, anaesthesiologist, paediatrician and the endocrinologist. Perioperative management for an emergency caesarean section in a parturient with untreated phaeochromocytoma is an anaesthetic challenge and no standard recommendations have been reported till date. In this case report, we present anaesthetic management in such a case with successful maternal and foetal outcome.

Enteric opportunistic parasites among HIV infected individuals: associated risk factors and immune status.

Data on various etiologic agents causing diarrhea in human immunodeficiency virus type-1 (HIV-1) infected individuals are sparse in Delhi, India. The present study was undertaken to identify various causative agents, the role of associated risk factors and immune status. A case-control study was conducted among 75 HIV-1 infected individuals, 50 with and 25 without diarrheal infection. Fecal samples were screened for coccidian parasites, enteric protozoa, and helminthes by using various staining techniques. The CD4+ T-lymphocyte count was estimated. Enteric parasites were identified among 62.7% individuals, of which Cryptosporidium emerged as the single largest pathogen predominant among 33% of the individuals (P < 0.025). Other parasites diagnosed that were significantly associated with diarrhea were Giardia lamblia (13.3%), microsporidia (6.7%), and Isospora belli (2.7%). Chronic infected diarrheal cases were found to have polyparasitic infections. The mean CD4+ cell count was found to be lower among the diarrheal cases when compared with the non-diarrheal cases (mean, 141 cells/mm(3) versus 390 cells/mm(3)). Similarly, among diarrheal individuals, the chronic diarrheal cases had a comparatively lower CD4+ cell count than the acute cases (mean, 123 cells/mm(3) versus 265 cells/mm(3)). Risk factors found significant during multivariate analysis were: residence in a slum, exposure to pets and animals, use of public toilets, and practice of unsafe homosexual activity. Enteric coccidian parasites were identified as significant agents associated with diarrhea, especially among those with improper hygiene, multiple infections and a lower CD4+ cell count. Thus, this study emphasizes the need for routine screening of enteric parasites as well as education about practicing personal hygiene and taking timely and appropriate prophylactic measures.