Adductor Canal Block Versus Local Infiltration Analgesia for Postoperative Pain Management in Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a common surgical procedure for patients with knee osteoarthritis, often associated with postoperative pain. Effective pain management strategies are essential for improving patient outcomes and satisfaction. This study aimed to compare the efficacy of two analgesic modalities, local infiltration analgesia (LIA) and adductor canal block (ACB), in providing postoperative pain relief for patients undergoing TKA. METHODS: This prospective randomized comparative study included 60 patients undergoing TKA for knee osteoarthritis under subarachnoid block (spinal anaesthesia). Patients were divided into two groups: LIA group (local wound infiltration with periarticular injection of bupivacaine 0.125% + dexmedetomidine 1 mcg/kg) and ACB group (ACB with bupivacaine 0.125% + 1 mcg/kg dexmedetomidine). Pain relief was assessed using the Numerical Rating Scale (NRS) score, time to first rescue analgesic requirement (NRS > 3), and total amount of analgesic needed in the first 24 hours post-surgery. RESULTS: The time to first perception of pain with NRS > 3 was 11.30±0.8 hours in the ACB group and 9.40 ± 1.1 hours in the LIA group, with a statistically significant difference (p < 0.001). Additionally, the total number of rescue analgesic doses given in the first 24 hours post-operatively differed significantly between the two groups (p = 0.046). CONCLUSION: The study concludes that ACB is an effective postoperative analgesic modality, superior to local infiltration analgesia, for patients undergoing TKA.

Dexmedetomidine as Conduit for Non-Invasive Ventilation (NIV) Compliance in COVID-19 and Chronic Obstructive Pulmonary Disease (COPD) Patients in Intensive Care Unit (ICU) Setting: Case Series.

Non-compliance to the non-invasive ventilation (NIV) mask in a distressed hypoxemic patient is not an unusual finding, especially in desaturated coronavirus disease (COVID-19) or chronic obstructive pulmonary disease (COPD) patients with respiratory distress who require ventilatory support to improve oxygenation. Failure to achieve success with the non-invasive ventilatory support with the tight-fitting mask led to emergent endotracheal intubation. This was in view to avert consequences such as severe hypoxemia and subsequent cardiac arrest.  Sedation is an important component of ICU management for noninvasive mechanical ventilation to improve NIV compliance/tolerance. Including the various sedatives used, such as fentanyl, propofol, or midazolam, the most suitable agent to be used as a primary/sole sedative still remains unclear. Dexmedetomidine providing analgosedation without significant respiratory depression facilitates better tolerance of NIV mask application. This case series is a retrospective analysis of patients in whom dexmedetomidine bolus followed by infusion was observed to facilitate compliance to NIV with the tight-fitting mask. Herein, a case summary of six patients with acute respiratory distress who were dyspnoic, agitated have severe hypoxemia were put on NIV with dexmedetomidine infusion is being reported. They were extremely uncooperative as their RASS score (Richmond Agitation-Sedation score) was + 1 to +3, not allowing the application of the NIV mask. Due to their poor compliance with to use of the NIV mask, proper ventilation could not be achieved. Dexmedetomidine infusion (0.3 to 0.4 mcg/kg/hr) was used after a bolus dose (0.2-0.3 mcg/kg). The RASS Score of our patients was +2 or +3 before this intervention which became -1 or -2 after including dexmedetomidine in the treatment protocol. The low dose dexmedetomidine bolus and infusion thereafter showed to improve the patient's acceptance of the device. Oxygen therapy with this was shown to improve patient oxygenation by allowing the acceptance of the tight-fitting NIV face mask. In conclusion, this case series serves as evidence of the use of dexmedetomidine as an effective therapy to calm the agitated desaturated patient, thereby facilitating non-invasive ventilation in COVID-19 and COPD patients and promoting better oxygenation. This may, in turn, avoid endotracheal intubation for invasive ventilation and the associated complications.

Postoperative urinary retention: A controlled trial of fixed-dose spinal anesthesia using bupivacaine versus ropivacaine.

BACKGROUND AND AIMS: Following spinal anesthesia (SA), patient discharge is often delayed due to postoperative urinary retention (POUR), the incidence of which varies widely. The present study of bupivacaine versus ropivacaine in equianalgesic doses was taken to explore the correlation between time to void urine and time for complete functional recovery. MATERIAL AND METHODS: In this double-blinded study fifty adult patients were assigned to two groups (bupivacaine/ropivacaine) according to alternate case allocation for receiving SA for lower abdominal, perineal, and lower limb surgeries, lasting less than 2 h. Statistical analysis was conducted using an intention-to-treat approach, using Mann-Whitney test for nonparametric data. Primary outcome data could not be obtained for 14 out of the 50 patients due to perioperative bladder catheterization. No patients were lost to follow-up. RESULTS: Both the bupivacaine and ropivacaine groups were comparable in terms of ability to void (8.0 ± 2.3 vs. 7.0 ± 1.2 h; P > 0.05), modified Bromage scale after 4 h of SA (1.8 ± 1.3 vs. 2.6 ± 0.9 grade; P > 0.05), time to complete ambulation (6.7 ± 1.4 vs. 6.1 ± 1.0 h; P > 0.05), and time to negative Romberg test (6.1 ± 1.4 vs. 5.6 ± 0.9 h; P > 0.05), respectively. Strong positive correlations (r = 0.7-0.9) were found between time to void urine and time for complete ambulation. CONCLUSIONS: Time to void urine and recovery of motor functions were found comparable statistically when bupivacaine and ropivacaine were used in the doses of 12.5 and 18.75 mg, respectively, for SA. However, group ropivacaine required lesser time to void and no patient developed POUR. Time to void urine was more than the time for ambulation. This may indicate a need for "selective spinal anesthesia" or adjuvant combination technique to accelerate the resolution of a block for ambulatory surgery.

Low tension breast hydatid cyst--a case report.

INTRODUCTION: Features of low tension in breast hydatid cyst and symptoms secondary to cyst dying and disintegration are unique and not yet reported in the literature. MATERIAL AND METHOD: An young woman of 30 years complained about pain and vague swelling in the right breast during follow-up with albendazole therapy following second laparotomy for post-surgical residual cavity of hydatid cyst in the left lobe of the liver. Breast ultrasound was diagnostic. RESULTS: Segmental breast excision revealed a large dead hydatid cyst. Postoperative course was uneventful. CONCLUSIONS: Breast hydatid cyst may become symptomatic and hypotensive after start of albendazole therapy.

Table Tilt Versus Pelvic Tilt Position for Intrauterine Resuscitation during Spinal Anaesthesia for Caesarian Section.

BACKGROUND: This study was undertaken to compare the effects on intrauterine resuscitation by table tilt versus pelvic tilt position after spinal anaesthesia for Caesarian Section. PATIENTS #ENTITYSTARTX00026; METHODS: FIFTY ASA I AND II PATIENTS WHO FULFILLED THE ELIGIBILITY CRITERIA WERE ENROLLED IN THE STUDY AND WERE DIVIDED INTO TWO GROUPS: group W (Pelvic tilt with wedge under right hip and group L- (15(0)left lateral table tilt) and received spinal anaesthesia. The following parameters were recorded. Heart rate (HR), mean arterial pressure (MAP) at baseline, 2mins, 5 min and then 5 min thereafter. Mean height of block, Total no. of segments blocked, Onset Time of sensory block (in Minutes), ephedrine doses, incidence of hypotension & bradycardia, APGAR score at 1& 5 Minutes. RESULTS: The decrease in MAP was much more in wedged position as compared to table tilt position also the incidence of hypotension was 40% in wedged position as compared to 12% in table tilt position. Mean height of block, Total no. of segments blocked, and boluses of inj. ephedrine used were more in the wedged position than in table tilt position. CONCLUSION: Wedge placement caused increased incidence of hypotension and higher blockade after spinal anaesthesia as compared to left lateral table tilt position, there was no adverse effects on foetus and patients tolerated wedge better than left lateral table tilt position. Also surgery was easier to perform after wedge placement.

Feasibility and outcome of proximal catheter ileostomy - a pilot study.

BACKGROUND/AIM: Loop ileostomy has high complication rates and causes much patient inconvenience. This study was carried out to evaluate the feasibility and outcome of a proximal catheter ileostomy in place of loop ileostomy in patients treated by intestinal repair and/or resection-anastomosis. DESIGN: Prospective study. SETTING: J. N. Medical College Hospital, Aligarh Muslim University, Aligarh, India. PATIENTS AND METHODS: From November 2006 to November 2009, in all patients treated surgically by primary repair and/or resection-anastomosis of small and/or large bowel, we constructed a catheter ileostomy when a defunctioning proximal protective loop ileostomy was considered advisable. Catheter ileostomy was constructed in the fashion of catheter jejunostomy, with postoperative saline irrigation. RESULTS: Catheter ileostomy was performed in 20 patients in the 3-year period. The mean age of the subjects was 28.6 years and the male: female ratio was 1.86:1. Four patients died of septicemia and multiple organ failure unrelated to catheter ileostomy in the immediate postoperative period. Catheter ileostomy started functioning within 48 hours of the operation, and twice-daily irrigation was found sufficient in 81.25% of the surviving patients. Only one patient developed peritubal leak with mild skin excoriation that cleared within 5 days. Another patient with Koch's abdomen underwent conversion to loop colostomy on re-exploration for postoperative adhesive obstruction. There was no instance of intestinal leak. Ileostomy wounds closed spontaneously within 7-14 days of catheter removal, and none required formal closure. Hospital stay ranged from 12-35 days (mean: 23 days). CONCLUSIONS: Catheter ileostomy is effective in protecting intestinal anastomosis/repair; there is minimal morbidity and no catheter-related leak/mortality, and we recommend the procedure.

Isolated corrosive pyloric stenosis without oesophageal involvement: an experience of 21 years.

BACKGROUND AND STUDY AIMS: Corrosive ingestion is common in Asia and it is a frequent cause of morbidity secondary to intense fibrotic reaction and stricture formation of the oesophagus. Isolated corrosive pyloric stenosis without oesophageal involvement is an uncommon phenomenon. PATIENTS AND METHODS: All consecutive patients, with corrosive ingestion in the last two decades, were reviewed and analysed. Eleven out of 201 patients with corrosive ingestion had isolated gastric outlet obstruction. RESULTS: Patients' age ranged from 11 to 29 years with a male:female ratio of 1.75:1. All patients developed pyloric stenosis following ingestion of solution of acids. Barium study revealed complete/near-complete gastric outlet obstruction in all patients. On laparotomy, there was gastric dilatation in 10 patients, who underwent posterior gastrojejunostomy, whereas the stomach was contracted in one patient, and hence anterior gastrojejunostomy was performed. Seven patients were completely relieved of their symptoms; persistent postprandial epigastric fullness and/or dyspepsia was observed in four patients whose gastrojejunostomy stoma was found adequate on barium study, suggestive of gastric motility disorder. We did not encounter gastrojejunostomy-related complication of stomal ulcer/stenosis in our patients. CONCLUSION: Isolated corrosive pyloric stenosis is not as rare as is commonly thought. Gastrojejunostomy is effective, although a fair percentage of patients appear to develop gastric motility disorder secondary to corrosive injury.

Brief reports: nerve stimulator evoked motor response predicting a successful supraclavicular brachial plexus block.

BACKGROUND: We examined the success rate of supraclavicular brachial plexus block after the different evoked motor responses to nerve stimulation. METHODS: This multicenter observational study included 377 patients. For each block, the evoked motor response elicited at 0.25 mA for 2 milliseconds was recorded, 30 mL bupivacaine 0.25% was injected, and the block was observed for success or failure. RESULTS: Complete anesthesia occurred in 317 cases (84.1%). The success rate was 100% when the evoked motor response was simultaneous flexion of the third and fourth digits or flexion of all 4 digits (digits 2-5) with or without thumb opposition. CONCLUSION: Simultaneous flexion of the third and fourth digits with or without other digits is associated with the highest success rate of supraclavicular brachial plexus block.

Comparison of ramosetron and ondansetron for control of post-operative nausea and vomiting following laparoscopic cholecystectomy.

BACKGROUND: Post-operative nausea and vomiting (PONV) is common. 5HT 3 receptor antagonists are commonly used drugs for its prevention. A study was designed to compare the efficacy and safety of ramosetron and ondansetron in patients undergoing laparoscopic cholecystectomy (lap chole). MATERIALS AND METHODS: A prospective randomized case controlled study was conducted at J. N. Medical College Hospital, Aligarh Muslim University, Aligarh, India, in patients who underwent lap chole following intravenous administration of ondansetron (4mg) or ramosetron (0.3mg) at the end of surgery, and efficacy as well as side effects of ondansetron and ramosetron was documented and compared. RESULTS: One hundred and thirty adult females undergoing lap chole were studied - 65 patients in each of the two groups. In first 24 h after surgery, complete response (No PONV) was observed in 28 patients of the ondansetron group and in 32 patients of the ramosetron group (P>0.05). Complete response in the second 24 h after surgery was observed in 30 patients of the ondansetron group and in 45 patients of the ramosetron group (P<0.05). During the first and second 24 h, PONV requiring rescue antiemetic was significantly higher (P<0.05) in the ondansetron group as compared to the ramosetron group. Adverse drug effects in the post-operative period were observed in 11 and 8 patients in ondansetron and ramosetron groups respectively (P>0.05). CONCLUSION: Ramosetron was found safe and more effective antiemetic than ondansetron in patients undergoing lap chole.

Foreign body granuloma in the anterior abdominal wall mimicking an acute appendicular lump and induced by a translocated copper-T intrauterine contraceptive device: a case report.

INTRODUCTION: Intrauterine contraceptive devices may at times perforate and migrate to adjacent organs. Such uterine perforation usually passes unnoticed with development of potentially serious complications. CASE PRESENTATION: A 25-year-old woman of North Indian origin presented with an acute tender lump in the right iliac fossa. The lump was initially thought to be an appendicular lump and treated conservatively. Resolution of the lump was incomplete. On exploratory laparotomy, a hard suspicious mass was found in the anterior abdominal wall of the right iliac fossa. Wide excision and bisection of the mass revealed a copper-T embedded inside. Examination of the uterus did not show any evidence of perforation. The next day, the patient gave a history of past copper-T Intrauterine contraceptive device insertion. CONCLUSIONS: Copper-T insertion is one of the simplest contraceptive methods but its neglect with inadequate follow-up may lead to uterine perforation and extra-uterine migration. Regular self-examination for the "threads" supplemented with abdominal X-ray and/or ultrasound in the follow-up may detect copper-T migration early. To the best of our knowledge, this is the first report of intrauterine contraceptive device migration to the anterior abdominal wall of the right iliac fossa.

Specific evoked motor response for supraclavicular brachial block.

OBJECTIVE: To assess and evaluate the accuracy of individual types of evoked motor responses (EMRs) for prediction of successful surgical anesthesia following peripheral nerve stimulator (PNS) assisted supraclavicular block. METHODS: A prospective study was carried out over a period of one and half years from August 2004 to January 2006, at J. N. Medical College, Aligarh Muslim University, Aligarh, India, in 60 patients who underwent various elective operative procedures on the upper limb. Any of the EMR, such as forearm flexion or extension, carpal flexion, or extension, prono-supination, or finger flexion, at a definite current of 0.25 mA for 2 ms was taken as an end point for prediction of successful block, and a local anesthetic solution (0.375% Bupivacaine, 30 ml) was administered at that level. RESULTS: Complete surgical anesthesia was observed in those cases where EMR included: flexion of only second and third fingers (n=15/15) or flexion of all 4 fingers with thumb opposition (n=14/14) or uncommon flexion of all 4 fingers without movement of any other joint of the upper limb (n=2/2), suggesting a sensitivity of 100%. However, thumb opposition to the tip of the flexed little finger revealed a success rate of only 83% (n=5/6), and other EMRs were followed by high rates of inadequate surgical anesthesia or total failure. CONCLUSION: Specific EMR of flexion of second and third fingers, or all the 4 fingers are reliable predictors of complete surgical anesthesia following PNS assisted single injection supraclavicular nerve block with no incidence of pneumothorax and nerve damage.