Comparison of two different positions of an anaesthesiologist for ease of endotracheal intubation in adult patients: A randomised control trial.

BACKGROUND AND AIMS: Maintaining the airway with a cuffed endotracheal tube (ETT) in the trachea remains one of the most essential anaesthesia skills. Many parameters were described to assess the difficulty of intubation in the preoperative period, but none allow the prediction of all difficult intubations. The correct posture of the anaesthesiologist is also an important factor for successful endotracheal intubation. The aim of this study was. This study aimed to compare the impact of two different positions of an anaesthesiologist (sitting vs. standing) at the time of endotracheal intubation. METHODS: One hundred ten American Society of Anaesthesiologists (ASA) Physical Status I/II patients, aged between 17 to 65 years, Mallampati grade I/II, mouth opening 39-70 mm, thyromental distance (TMD) 6-6.5 cm, and sternomental distance (SMD) >13 cm, scheduled for elective laparoscopic cholecystectomy, were recruited. Patients were divided into two groups; Group I consisted of patients who underwent endotracheal intubation by an anaesthesiologist in a sitting posture, while Group II encompassed patients who underwent endotracheal intubation by anaesthesiologists in a standing posture. Assessment parameters include ease of intubation (IDS score), intubation time, intubation success rate, number of attempts, grade of laryngoscopy (Cormack Lehane score, POGO score), and complications like tooth and soft tissue damage. RESULTS: The ease of intubation was higher in group I, 1(0-1), than in group II, 1(1-2) (p = 0.02), and there was a significant difference between the two groups. The Cormack Lehane grade (CL) was I/IIa/IIb/III in 19/23/13/0 in group I and I/IIa/IIb/III in 13/21/18/3 in group II. The first-attempt intubation success rate for groups I and II was 94.54 % and 92.72 % respectively. CONCLUSION: The sitting posture of an anaesthesiologist at the time of laryngoscopy provides a better intubating condition when compared with the standing posture. REGISTRATION: Clinical Trial Registry - India (CTRI) CTRI/2023/03/050371.

Costoclavicular versus lateral sagittal infraclavicular brachial plexus block for postoperative analgesia in patients undergoing upper limb orthopaedic surgery: A randomised controlled trial.

Background and Aims: Perineural catheters inserted through the costoclavicular (CC) technique of infraclavicular brachial plexus are helpful for postoperative analgesia. This trial compared postoperative local anaesthetic (LA) consumption in an ultrasound (US)-guided perineural catheter inserted by the CC technique with the conventional lateral sagittal (LS) technique. Methods: Eighty American Society of Anesthesiologists (ASA) I/II patients scheduled for upper limb orthopaedic surgery were randomly assigned to receive a perineural catheter by either the CC technique (Group CC) or LS technique (Group LS). Postoperatively, all patients received patient-controlled regional analgesia (PCRA): bolus-only regime with 0.125% bupivacaine 6 ml and a lock-out interval of 20 minutes. The primary outcome was the 24 h LA consumption. The secondary outcomes were time of activation of PCRA, pain scores, patient satisfaction scores, and block-related complications. Categorical variables are presented as frequency, while continuous variables are expressed as mean [standard deviation (SD)] or median [interquartile range (IQR)]. An independent t-test or Mann-Whitney U-test was used to compare these continuous variables. A P value less than 0.05 was considered to be statistically significant. Results: Patients in Group CC required less LA 24 h postoperatively (P < 0.001) and more time to activate PCRA (P = 0.003). The mean 24 h LA requirement was 83.35 (SD: 31.92) in Group CC as compared to 121.40 (SD: 48.51) ml in Group LS. They also reported better satisfaction scores (P = 0.001). Pain scores were comparable at all time points. Postoperatively, one patient in Group CC complained of paraesthesia, which subsided on removal of the catheter. Conclusion: Patients receiving post-operative analgesia by the CC catheter require lesser 24 h LA and report better satisfaction than those receiving analgesia through the LS technique.

Opioid-free anesthesia using a combination of ketamine and dexmedetomidine in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: Opioids administered as bolus doses or continuous infusions are widely used for major and daycare surgeries. Opioid-free anesthesia is multimodal anesthesia and analgesia that does not use opioids, benefiting patients from opioid-related adverse effects. We compared the postoperative analgesic requirements of patients scheduled for elective laparoscopic cholecystectomy under opioid-free and opioid-based anesthesia. METHODS: Study included 88 patients aged 18-60 years with American Society of Anesthesiologists physical status 1 and 2 who underwent elective laparoscopic cholecystectomy. Participants were randomly divided into two groups with 44 in each. The opioid-free group was administered an intravenous bolus of ketamine and dexmedetomidine, whereas fentanyl was used in opioid group. Primary outcome was to compare the total amount of fentanyl consumed by both groups during 6 h postoperative period. Episodes of postoperative nausea and vomiting (PONV) and vital signs were noted throughout the postoperative period to analyze the secondary outcomes. RESULTS: Both groups had similar demographic characteristics. The opioid-free group required lesser analgesia within the first 2 h (61.4 ± 17.4 vs. 79.0 ± 19.4 of fentanyl, P < 0.001), which was statistically significant. However, fentanyl consumption was comparable between the groups at 6 h (152 ± 28.2 vs. 164 ± 33.4, P = 0.061). Compared with 4.5% of the participants in the opioid-free group, 34% of those in the opioid-based group developed moderate PONV. CONCLUSIONS: Opioid-free anesthesia in patients undergoing laparoscopic cholecystectomy reduced the requirement of analgesia in first two-hour postoperative period and was associated with decreased PONV.

Effect of different doses of dexmedetomidine as an adjuvant to lignocaine nebulization: A comparative study during awake flexible fiberoptic bronchoscopy.

Background and Aims: Mild to moderate sedation during bronchoscopy is essential for patient safety, comfort during and after the procedure, and to facilitate the performance of the bronchoscopist. Dexmedetomidine is a highly selective, centrally acting α-2 agonist used to provide conscious sedation during various procedures. The aim of this study was to compare the efficacy of three different doses of dexmedetomidine nebulization as an adjuvant to lignocaine during bronchoscopy. Material and Methods: Ninety American Society of Anesthesiologists physical status I/II patients, aged from 18 to 60 years, scheduled for an elective bronchoscopy, were recruited. They were divided into three groups: 30 patients in each group. Group I: The patient was nebulized with a mixture of 4 ml of 4% lignocaine and dexmedetomidine 0.5 µg/kg. Group II: The patient was nebulized with a mixture of 4% lignocaine, 4 ml, and dexmedetomidine, 1 µg/kg. Group III: The patient was nebulized with 4% lignocaine 4 ml and dexmedetomidine 1.5 µg/kg. Results: The mean cough score was (1.17 ± 0.37), (1.40 ± 0.49), and (1.70 ± 0.75) in group III, group II, and group I, respectively. A significant difference was found between the groups. Patients were more comfortable with a statistically significant difference in the comfort score in group III as compared to group II and group I. Conclusion: Dexmedetomidine nebulization in a dose of 1.5 µg/kg (compared to 1 µg/kg or 0.5 µg/kg) as an adjuvant to lignocaine, provides better bronchoscopy conditions and patient satisfaction.

Comparative evaluation of nebulised dexmedetomidine vs fentanyl for the treatment of post-dural puncture headache (PDPH) in parturients after caesarean section under spinal anaesthesia: A randomised controlled study.

Background and Aims: The incidence of post-dural puncture headache (PDPH) following spinal anaesthesia in the obstetric population is around 0.5%-2%. Hydration, bed rest, caffeine, paracetamol, non-steroid anti-inflammatory drugs, epidural blood patches, etc., are the various modalities used for its management. This study aims to compare nebulised dexmedetomidine versus fentanyl for the treatment of PDPH in parturients after caesarean section under spinal anaesthesia. Methods: Ninety obstetric patients aged 18-35 years with American Society of Anesthesiologists (ASA) physical status II/III and suffering from PDPH as per the criteria of the International Headache Society after caesarean section under spinal anaesthesia were recruited in this double-blinded randomised study. Patients were randomised to Group D (dexmedetomidine 1 µg/kg nebulisation), Group F (fentanyl 1 µg/kg nebulisation), and Group S (saline nebulisation 4mL). The nebulisation was done 12 hourly for 72 hours. Assessment parameters included pain score and the requirement of additional treatment such as paracetamol, caffeine, and epidural blood patch. Analysis of variance test was used for continuous quantitative variables, and the Kruskal-Wallis test was used for quantitative discrete data. Results: The pain scores at 1, 6, 12, 24, 48, and 72 hours following nebulisation were significantly lower in Group D in comparison to groups F and S (P < 0.001). The number of patients requiring additional analgesic therapy was lower in Group D in comparison to patients in other groups (P < 0.001). Conclusion: Dexmedetomidine nebulisation resulted in effective reduction in PDPH symptoms and pain scores. Nebulisation with fentanyl did not alleviate PDPH symptoms when compared to the control group.

Modified Thoracolumbar Interfascial Plane Block Versus Erector Spinae Plane Block in Patients Undergoing Spine Surgeries: A Randomized Controlled Trial.

BACKGROUND: Lumbar spine surgery is associated with significant postoperative pain. Interfascial plane blocks, such as erector spinae plane (ESP) and thoracolumbar interfascial plane (TLIP) blocks, can play a significant role in multimodal analgesic regimens. METHODS: Sixty patients aged 18 to 60 years undergoing elective single or double-level lumbar discectomy or primary lumbar laminoplasty were recruited into this randomized double­blind study. All patients received general anesthesia and were randomly allocated to either modified TLIP (mTLIP) block (group M) or ESP block (group E). Postoperative and intraoperative fentanyl consumption, and postoperative pain scores, were recorded. RESULTS: Total 48 h postoperative fentanyl consumption was higher in Group M (189.66±141.11 µg) than in Group E (124.16±80.83 µg; P =0.031). In the first 24 postoperative hours, fentanyl consumption was higher in Group M (150.3±120.9 µg) than in group E (89.9±65.3 µg; P =0.01) but was similar between groups in postoperative hours 24to 48 (39.0±20.2 µg versus 34.7±17.1 µg in group M and group E, respectively; P =0.37). Additional intraoperative fentanyl requirement was 57.66±21.76 µg in group M compared with 40.33±21.89 µg in group E ( P <0.01). Postoperative pain scores were higher in group M than in group E at 1, 2, 4, 6, 12, and 24 hours postoperatively ( P <0.001), but similar at 48 hours ( P =0.164). CONCLUSION: Compared with the mTLIP block, the ESP block was associated with lower pain scores and a small decrease in perioperative fentanyl consumption in patients undergoing lumbar spine surgeries. Both blocks could form a part of a multimodal analgesic regimen in spine surgery patients.

Comparison of the efficacy of pericapsular nerve group block (PENG) block versus suprainguinal fascia iliaca block (SFIB) in total hip arthroplasty: A randomized control trial.

Background and Aims: Hip replacement surgery is a commonly performed surgery with the aim of improving mobility in patients suffering from hip conditions. Though the modified suprainguinal approach of fascia iliaca block (SFIB) is commonly used, the analgesic efficacy is moderate and is associated with quadriceps weakness. The pericapsular nerve group (PENG) block has been used to block the sensory articular branches of the hip joint in various hip surgeries. This study aimed to compare SFIB with PENG block in terms of pain relief, opioid consumption and their adverse effects in patients undergoing primary total hip arthroplasties. (THA). Methods: Seventy ASA I/II patients undergoing primary THA were enrolled in this double-blinded, randomized trial. Patients were randomly allocated to one of the two groups: Group P: ultrasound (US)-guided PENG block and Group S: patients received the US-guided SFIB. Results: Postoperatively, there was statistically significant difference in numerical rating scale (NRS) scores at all-time intervals. Total morphine consumption in 24 hours and 48 hours was statistically more in SFIB group. Five patients had quadriceps weakness in the SFIB group. There was no difference in any other adverse effects. Conclusion: US-guided PENG block significantly reduces perioperative morphine consumption and pain scores in THA patients when compared to SFI block. It is not associated with quadriceps weakness as seen in SFIB.

Comparison between in-plane and out-of-plane techniques for ultrasound guided cannulation of the left brachiocephalic vein in pediatric population: A randomised controlled trial.

BACKGROUND AND AIMS: Brachiocephalic vein is a novel site for central venous cannulation in infants. It becomes useful in patients where the internal jugular vein lumen is small (e.g., volume deficient patient), patients with a history of multiple cannulations, and in whom subclavian puncture is contraindicated. METHODS: In this randomized double-blinded study, 100 patients, aged between 0 and 1 year scheduled for elective central venous cannulation were recruited. The patients were allocated into two groups (50 patients in each). Group I patients had ultrasound (US) guided cannulation of the left brachiocephalic vein (BCV) by inserting a needle in-plane to the US probe from lateral to the medial direction, whereas Group II patients underwent cannulation of the BCV via an out-of-plane approach. RESULTS: The first-attempt success rate was significantly higher in Group I (74%) than in Group II (36%) (p < 0.001). The total success rate was higher in group I (98%) than in group II (88%) however the difference was statistically insignificant (p > 0.05). The mean BCV cannulation time was significantly shorter in group I (35.46 ± 25.10) than in group II (65.24 ± 40.26) (p < 0.001). The rate of unsuccessful BCV cannulation (12%) and hematoma development (12%) was significantly higher in group II than in group I (2%). CONCLUSION: Compared to the out-of-plane approach of left BCV cannulation, US-guided in-plane cannulation of the left BCV increased the first-attempt success rate, decreased the number of puncture attempts, and decreased the time required for cannulation.

The role of point of care thromboelastography (TEG) and thromboelastometry (ROTEM) in management of Primary postpartum haemorrhage: A meta-analysis and systematic review.

Background: The utility of instantaneous evaluation of coagulation during primary postpartum haemorrhage (PPH) is paramount in the context of empirical blood product transfusion-related risk of dilutional and consumptive coagulopathy and circulatory overload. Methods: A profound screening of electronic databases till August 15, 2022 was carried out after being enlisted in PROSPERO (CRD42021275514). Randomized control studies, comparative cohort studies, and cross-sectional studies comparing point-of-care viscoelastic test guided blood product transfusion with empirical transfusion in patients with PPH were included. Results: We retrieved five studies, with a total of 1914 parturient with PPH. Patients receiving transfusion based upon point of care viscoelastic tests had lesser risk of having emergency hysterectomy (Odds ratio (OR) = 0.55, 95% CI 0.32-0.95, I2 = 7%), transfusion-associated circulatory overload (TACO) (OR = 0.03, 95% CI 0.00-0.50), reduced transfusion of fresh frozen plasma (OR = 0.07, 95% CI 0.04-0.14, I2 = 89%), platelets (OR = 0.51, 95% CI 0.28-0.91, I2 = 89%), packed red blood cell transfusion (OR = 0.70, 95% CI 0.55-0.88, I2 = 89%), and had better cost-effective treatment [Mean difference (MD) = -357.5, 95% CI - 567.75 to -147.25, I2 = 93%] than patient received empirical transfusion. However, there was no significant difference in the requirement of ICU admissions (OR = 0.77, 95% CI = 0.46-1.29, I2 = 82%). No mortality was detected across the studies. Conclusions: Point of care viscoelastic assessment guided transfusion in PPH confederates with reduced morbidity. Nevertheless, more studies on the triggering values for transfusion, long-term survival, and cost-benefit in patients with PPH are warranted to establish its utility.