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.

Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery.

BACKGROUND: Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia. OBJECTIVES: To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality. SEARCH METHODS: On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome. MAIN RESULTS: Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias. AUTHORS' CONCLUSIONS: Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.

Single Orifice Outflow Reconstruction: Refining the Venous Outflow in Modified Right Lobe Live Donor Liver Transplantation.

BACKGROUND: MHV reconstruction is essential to avoid anterior sector congestion in adult live donor liver transplantation (LDLT) using a modified right lobe graft. AIMS: The objective of this study is to evaluate the graft and patient outcomes with single orifice outflow reconstruction technique (SORT) (RHV + neo-MHV combined reconstruction on IVC) vs. dual outflow reconstruction technique (DORT) (RHV and neo-MHV separately reconstructed on IVC) in a modified right lobe LDLT. METHODS: Prospectively collected data of consecutive patients undergoing LDLT from June 2011 to August 2018 were analyzed. The patients were divided into two groups: SORT (n = 207) and DORT (n = 108). The perioperative morbidity and mortality were compared between two groups. RESULTS: The two groups were comparable in baseline preoperative characteristics. Intraoperatively, warm ischemia time (27 vs. 45 min, p < 0.001), anhepatic phase (132 vs. 159 min, p < 0.001), and operative time (680 vs. 840 min, p < 0.001) were significantly shorter in SORT group. SORT group also had significantly lower GRWR (0.92 vs. 1.06, p < 0.001) and higher portal flow (2.4 vs. 2.7 L/min, p = 0.02). Postoperatively, SORT group had lower peak AST (177 vs. 209 IU/L, p < 0.001), ALT (163 vs. 189 IU/L, p = 0.004), creatinine levels (0.98 vs. 1.10, p = 0.01), rate of severe sepsis (13.7% vs. 22.9%, p = 0.03), major morbidity (50.7% vs. 62.6%, p = 0.03), shorter ICU (9 vs. 14 days, p < 0.001), and hospital stay (21 vs. 26 days, p = 0.03). Overall survival rates were comparable. CONCLUSION: A SORT leads to improved early graft function and perioperative morbidity in modified right lobe LDLT in spite of having lower GRWR and higher portal flow.

Living donor liver transplantation in a patient with cocoon abdomen - Anesthesia concerns!

Cocoon abdomen is a rare condition in which abdominal structures are surrounded by thick encapsulating peritoneum resulting in dense adhesions. Liver transplant is a high risk surgery with an already increased risk of massive blood loss due to the pre-existing coagulopathy and portal hypertension. Presence of cocoon abdomen with severe dense adhesions can either lead to difficult hepatectomy with massive intra-operative blood loss or failure to proceed with the surgery. This becomes even more important in live donor liver transplantation where it may not be possible to abandon the surgery once the donor liver resection is started. Thus keeping a high suspicion of cocoon abdomen in patients with previous history of kochs abdomen and on long term beta blocker therapy is of utmost importance and this can decrease the morbidity and mortality associated with this condition. A 41 year old male known case of chronic liver disease was posted for live donor liver transplantation. After opening the abdomen thick dense adhesions were found around the intestines and the liver. Due to the dense adhesions surgical team was in dilemma whether to proceed further for the surgery or not. Intra-operatively patient had a blood loss of 12.5 litre. Despite massive transfusion the postoperative course went uneventful and the patient was extubated on 2nd post-operative day. He was shifted out of Intensive care unit on the 6th post-operative day. Cocoon abdomen should be suspected in a chronic liver disease patient with previous history of tuberculosis or on long term beta blocker therapy. Proper preparation before surgery can decrease the morbidity and mortality associated with this major surgery. Our case report clearly shows that such types of patients can be taken up for the live donor liver transplantation surgery with a precaution to start donor hepatectomy only after surgeon has assessed the difficulty status of recipient hepatectomy.

Comparison of caudal epidural block with paravertebral block for renal surgeries in pediatric patients: A prospective randomised, blinded clinical trial.

STUDY OBJECTIVE: This study was undertaken to compare the analgesic efficacy of ultrasound-guided single-shot caudal block with ultrasound-guided single-shot paravertebral block in children undergoing renal surgeries. DESIGN: Randomised, interventional, blinded clinical trial. SETTING: Operating rooms of All India Institute of Medical Sciences, New Delhi, India. PATIENTS: 50 children aged 2-10 years, of ASA status I/II, posted for elective renal surgeries. INTERVENTIONS: The children were randomised into two groups (Group C-caudal block, Group P-paravertebral block). After induction of general anesthesia, single-shot caudal or paravertebral block was performed under ultrasound guidance, with 0.2% ropivacaine with 1:200000 adrenaline. MEASUREMENTS: Time to first rescue analgesia, time to perform blocks, intraoperative and post-operative hemodynamics, post-operative FLACC scores, incidence of complications, parental satisfaction scores were recorded. MAIN RESULTS: Children in Group P had significantly longer duration of analgesia (p < 0.0004) than Group C. Post-operative FLACC scores (p < 0.005) and analgesic requirements (p < 0.0004) were lower in Group P. The mean fentanyl requirement over 24 h in group P was 0.56 ±â€¯0.82 µg/kg, compared to 1.8 ±â€¯1.2 µg/kg in group C. Parents in Group P reported greater satisfaction (p < 0.02). No complications were seen in either of the groups. CONCLUSION: This study showed superior analgesia and parental satisfaction with single-shot paravertebral block in comparison to single-shot caudal block for renal surgeries in children. However, the block performance in children requires adequate expertise and practice.

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.

Caudal bupivacaine and morphine provides effective postoperative analgesia but does not prevent hemodynamic response to pneumoperitoneum for major laparoscopic surgeries in children.

The use of a caudal block in laparoscopic surgery in children is limited to minor procedures like inguinal hernia repair, and intravenous opioids remain the analgesic modality of choice in major laparoscopic surgery. However, a caudal block is frequently performed at our institute even for laparoscopic surgery. Therefore, we planned to evaluate the analgesic efficacy of caudal bupivacaine and morphine in major laparoscopic surgery as compared to intravenous opioids. Our hypothesis was that a single-shot caudal block would increase the duration of analgesia and minimize the hemodynamic response to pneumoperitoneum. After institutional ethics committee clearance, data were collected for 65 ASA I-II children aged 6 months to 12 years who underwent laparoscopic surgery in the last 14 months. Demographic, surgical, and perioperative anesthetic and analgesic data were noted and analyzed. Twenty-four children received a caudal block with 0.25 % bupivacaine (1-1.25 ml/kg) with morphine (30-50 mcg/kg). In the caudal group, the time to first analgesic request was increased (165 vs. 45 min; p = 0.00) and tachycardia response to port site incision was less observed (33 vs. 63 % children; p = 0.019). Hemodynamic response to pneumoperitoneum was equal in both of the groups. Single-shot caudal injection of local anesthetic with morphine reduces port site skin incision response and increases the duration of postoperative analgesia but fails to prevent hemodynamic response to pneumoperitoneum.

Epidural anesthesia and analgesia in the neonate: a review of current evidences.

The role of single shot spinal anesthesia has been established in ex-premature infants at risk of apnea. However, use of epidural anesthesia in neonates is on the rise. In this systematic analysis, we have reviewed the current evidence on the safety and efficacy of the use of single shot and continuous epidural anesthesia/analgesia in neonates. Current clinical practice is guided by evidence based mostly on non-randomized studies, prospective/retrospective case series and surveys. Single shot caudal blockade as a sole technique has been used in neonates mainly for inguinal hernia repair and circumcision. Use of continuous epidural anesthesia through the caudal route or caudo-thoracic advancement of the catheter for major thoracic and abdominal surgery offers good perioperative analgesia. Other observed benefits are early extubation, attenuation of stress response, early return of bowel function and reduction of general anesthesia-related postoperative complications. However, risk of procedure-related and drug-related complications to the developing neural structure remains a serious concern.

A retrospective analysis of determinants of self-extubation in a tertiary care intensive care unit.

BACKGROUND: Self-extubation is a common event in intensive care units (ICUs) world-wide. The most common factor attributed in various studies is lack of optimal sedation. However, the factors that lead to this inadequacy of sedation are not analyzed. AIMS: The present study aimed to evaluate the determinants of factors leading to self-extubation in our ICU. Relation of patient profile, nature of sedation and any diurnal variation in extubation frequency was analyzed. MATERIALS AND METHODS: Retrospective explorative analysis was carried out for patients admitted to ICU from January 2011 to January 2012. Information from medical records for the above parameters was extracted and descriptive statistics was used for assessing the outcomes. RESULTS: In the present study, there was a higher incidence of self-extubation in ventilated ICU patients during the changeover periods of the ICU staff. There was no relation of frequency of self-extubation with the medications used for sedation once the sedation was titrated to a common endpoint. A higher incidence of self-extubation was seen in the surgical and younger age group of patients. CONCLUSIONS: It is recommended that the duty shift finishing time of ICU staff (medical and paramedical) staff should be staggered and should have minimal overlap to prevent self-extubation. A continuous reassessment of level of sedation of patients independent of the type sedative medication should be carried out.

Perioperative concerns in pediatric patients u10/1/2013ndergoing different types of scoliosis correction surgery: A retrospective observational study.

BACKGROUND: Advances in scoliosis surgery have now made it possible for younger patients to be taken up for scoliosis correction. OBJECTIVES: To ascertain the patient profile, perioperative complications and need for intensive care management in children undergoing posterior fusion and instrumentation (PF), anterior release (AR), and growth rod (GR) insertion surgery. PATIENTS AND METHODS: After taking parental consent, data were collected retrospectively for 33 patients who underwent 37 procedures (four patients had both anterior and posterior procedures) on 2 days of the week mainly from August 2008 to February 2010 at a tertiary care institution. RESULTS: Children undergoing GR surgery were younger (8.1 ± 2.1 years) than patients undergoing AR (12.9 ± 1.7 years) or posterior fusion (14.2 ± 2.2 years). AR children had a significantly higher Cobb's angle and more rigid curves. (P = 0.057) Associated congenital abnormalities especially neurological were commoner in the GR children. Surgical duration and blood loss was significantly more for PF (2207.5 ± 1224.13 ml) than GR (456 ± 337.5 ml), or AR (642.85 ± 304.72 ml), (P = 0.0002). PF patients needed Intensive care unit (ICU) care mainly due to the blood loss and prolonged surgery (35%). AR performed via thoracotomy was associated with the need for mechanical ventilation in 28.6%. The GR patients had major intraoperative hemodynamic events and 20% needed ICU care. CONCLUSIONS: Post-operative ventilation may be required in 20-35% patients undergoing procedures for scoliosis correction. Despite GR insertion involving lesser blood loss; younger age, congenital abnormalities, positioning, and surgical manipulation resulted in life threatening events in these patients.

Pregabalin in acute and chronic pain.

Pregabalin is a gamma-amino-butyric acid analog shown to be effective in several models of neuropathic pain, incisional injury, and inflammatory injury. In this review, the role of pregabalin in acute postoperative pain and in chronic pain syndromes has been discussed. Multimodal perioperative analgesia with the use of gabapentinoids has become common. Based on available evidence from randomized controlled trials and meta-analysis, the perioperative administration of pregabalin reduces opioid consumption and opioid-related adverse effects in the first 24 h following surgery. Postoperative pain intensity is however not consistently reduced by pregabalin. Adverse effects like visual disturbance, sedation, dizziness, and headache are associated with higher doses. The advantage of the perioperative use of pregabalin is so far limited to laparoscopic, gynecological, and daycare surgeries which are not very painful. The role of the perioperative administration of pregabalin in preventing chronic pain following surgery, its efficacy in more painful surgeries and surgeries done under regional anesthesia, and the optimal dosage and duration of perioperative pregabalin need to be studied. The efficacy of pregabalin in chronic pain conditions like painful diabetic neuropathy, postherpetic neuralgia, central neuropathic pain, and fibromyalgia has been demonstrated.

Entropy monitoring decreases isoflurane concentration and recovery time in pediatric day care surgery--a randomized controlled trial.

AIM: To assess if titrating anesthesia with entropy would result in faster awakening in children undergoing day care surgery. BACKGROUND: Entropy, an EEG-based anesthesia depth monitor, has been used in children; however, only one other study has evaluated the effectiveness of entropy monitoring in decreasing awakening time and for titrating anesthetic agents in children undergoing short procedures under anesthesia. METHODS: In a randomized prospective single-blind parallel group trial, 50 ASA grade I-II children, aged 2-12 years, scheduled for lower abdominal or urological surgeries were studied after ethics committee approval and parental consent. The children were randomized to the entropy or control group. Following laryngeal mask airway insertion and caudal analgesia, anesthesia was maintained with nitrous oxide, oxygen, isoflurane. In the control group, anesthesia was titrated according to the hemodynamic parameters and the simultaneously monitored entropy values obscured from the anesthesiologist. In the entropy group, the entropy values (between 45 and 65) were used to titrate the anesthesia. RESULTS: Time to awakening from anesthesia was 7 (3-18) min in the entropy group when compared to 10 (5-21) min in the control group. (P < 0.05) The difference in the mean time to awakening was 2.72 min 95% CI (0.34, 5.1). The end tidal isoflurane concentrations were lower in the entropy group when compared to the control group 15 s following airway insertion (0.78 ± 0.14 vs 1.24 ± 0.19), 15 s post caudal and skin incision (0.68 ± 0.40 vs 0.84 ± 0.05, 0.68 ± 0.03 vs 0.77 ± 0.32, respectively) as well as 5 min after skin incision 0.67 ± 0.04 vs 0.79 ± 0.02), (P ≤ 0.05). CONCLUSION: In pediatric day care surgery, entropy monitoring resulted in statistically though not clinically significant faster awakening and significantly lower end ­ tidal isoflurane concentrations.