Effect of ultrasound-guided quadratus lumborum block on neuroendocrine stress response and postoperative analgesia in paediatric patients undergoing elective open pyeloplasty - A randomised clinical trial.

Background and Aims: Quadratus lumborum block (QLB) is a compartmental block of the anterior abdominal wall. Surgical trauma produces neuroendocrine surgical stress responses, which are modified by anaesthetic blocks. The aim of this study was to evaluate the effect of ultrasound (US)-guided QLB on analgesia and surgical neuroendocrine stress response in paediatric patients undergoing pyeloplasty. Methods: A randomised trial was conducted in 60 children aged 1-7 years undergoing elective open pyeloplasty. Patients were randomised into Group QLB [US-guided QLB with 0.5 ml/kg of 0.25% ropivacaine after induction of general anaesthesia (GA)], and Group GA, which received only GA. Perioperative haemodynamic parameters, serum cortisol, blood glucose, analgesic consumption and postoperative FLACC scores were recorded. Unpaired t-test, Wilcoxon rank-sum test or Mann-Whitney U test was used to compare variables between the two groups. Two-way analysis of variance or the Friedmann test was used to compare quantitative variables at various points within a group. Results: A decrease in serum cortisol and blood glucose values was observed in Group QLB at 30 min after surgical incision and 24 h after surgery compared to the preoperative value and compared to Group GA (P < 0.05). The quality of analgesia assessed by the FLACC scale was significantly better in group QLB. Dose of fentanyl consumption (µg/kg) was higher in Group GA compared to Group QLB in the intraoperative and postoperative period (P < 0.05). Conclusion: QLB is effective as part of multimodal analgesia and attenuates the neuroendocrine stress in paediatric patients undergoing open pyeloplasty.

USG-guided continuous erector spinae block as a primary mode of perioperative analgesia in open posterolateral thoracotomy: A report of two cases.

The postoperative pain management in open thoracotomy is very crucial as the effective analgesia can prevent respiratory and thrombotic complications and lead to early mobilization and discharge. The thoracic epidural analgesia is the gold standard in such surgeries; however, there are few adverse effects such as hypotension, dural puncture, and contralateral block that always warrants safer alternative. Recently, with the advent of ultrasound, the regional anesthetic techniques are getting more popular to avoid such complications. Erector spinae plane (ESP) block is one of the novel techniques that has been described as a safe thoracic paravertebral block. We are reporting here the continuous ESP block as a primary mode of postoperative analgesia which was continued for 48 h. The intraoperative opioid requirement was very less, and the maximum NRS score in postoperative period was 4 at 12 h, which was well managed with multimodal analgesic regimen along with rescue doses of opioid.

Granisetron versus Granisetron-Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Randomized Double-Blind Trial.

Aim. Efficacy of granisetron and combination of granisetron and dexamethasone was evaluated for prevention of postoperative nausea and vomiting (PONV) in children undergoing elective strabismus surgery. Methods. A total of 136 children (1-15 years) were included. Children received either granisetron (40 mcg/kg) [group G] or combination of granisetron (40 mcg/kg) and dexamethasone (150 mcg/kg) [group GD]. Intraoperative fentanyl requirement and incidence and severity of oculocardiac reflex were assessed. PONV severity was assessed for first 24 hours and if score was >2, it was treated with metoclopramide. Postoperative analgesia was administered with intravenous fentanyl and ibuprofen. Results. The demographic profile, muscles operated, and fentanyl requirement were comparable. Complete response to PONV in first 24 hours was observed in 75% (51/68) of children in group G and 76.9% (50/65) of children in group GD, which was comparable statistically (p = 0.96, Fisher exact test; OR 1.11, 95% CI 0.50, 2.46). Incidence of PONV between 0 and 24 hours was comparable. One child in group G required rescue antiemetic in first 24 hours and none of the children had severe PONV in group GD. There was no significant difference in incidence or severity of oculocardiac reflex. Conclusion. Dexamethasone did not increase efficacy of granisetron for prevention of PONV in elective pediatric strabismus surgery. Registration number of clinical trial was CTRI/2009/091/001000.

Perioperative management and post-operative course in preterm infants undergoing vitreo-retinal surgery for retinopathy of prematurity: A retrospective study.

BACKGROUND: Premature infants scheduled for surgery under general anesthesia are more prone to cardio-respiratory complications. Risk factors include post-conception age (PCA), cardiac and respiratory disease, anemia and opioid administration. This retrospective study evaluates the perioperative management and post-operative course (apnea and bradycardia) in premature infants undergoing surgery for retinopathy of prematurity (ROP). MATERIALS AND METHODS: We analyzed the pre-operative data, anesthesia chart and post-operative course of 52 former premature infants for 56 general anesthesia exposures for ROP surgery. RESULTS: At the time of procedure, median PCA was 51 (36-60) weeks. 71% of the infants were above 46 weeks of PCA. Five infants had cardiac disease and four had a history of convulsion. Four infants had a pre-operative history of apneic spells. The airway was secured with either endotracheal tube (46) or supraglottic device (10). Fentanyl (0.5-1 µg/kg), paracetamol, topical anesthetic drops and/or peribulbar block were administered for analgesia. Extubation was performed in the operating room for 54 cases. Three infants had apnea post-operatively. Seven infants were shifted to neonatal intensive care unit either for observation or due to delayed recovery, persistent apneic spells and pre-existing cardio-respiratory disease. CONCLUSION: In the present study, intravenous paracetamol and topical anesthetics reduced the total intra-operative opioid requirement, which resulted in low incidence of post-operative apnea. Regional anesthesia may be considered in infants with high risk of post-operative apnea. Infants with PCA > 42 weeks and without any co-morbidity can be managed in post-anesthesia care unit.

Efficacy of diltiazem as an adjunct to lignocaine in intravenous regional anesthesia.

BACKGROUND: Various adjuncts have been used with lignocaine to decrease tourniquet pain and prolong post-operative analgesia during intravenous regional anesthesia (IVRA). Calcium-channel blockers potentiate the analgesic effect of local anesthetics. This study was designed to evaluate the efficacy of diltiazem as an adjunct to lignocaine in IVRA with respect to tourniquet tolerance, perioperative analgesia, and quality of anesthesia. METHODS: In this prospective, randomized, and double-blind study, 40 patients (American Society for Anesthesiologists grade I/II) undergoing elective hand surgery under IVRA were assigned into two groups of 20 each and administered IVRA either with lignocaine 3 mg/kg (group Lignocaine (L)) or lignocaine 3 mg/kg plus diltiazem 0.2 mg/kg (group Lignocaine-Diltiazem (LD)) with normal saline (total volume-40 ml). Hemodynamic parameters, onset of the complete sensory blockade, motor blockade, and intraoperative (tourniquet pain) and post-operative Visual Analogue Scale scores, total intraoperative and consumption of post-operative fentanyl intraoperative were recorded. RESULTS: Sensory block was established in 2.5±0.688 min in group LD verses 5.60±0.851 min in group L. Motor blockade was established in 8.65±0.933 min in group LD and 13.46±0.604 min in group L. The mean VAS scores >3 were attained early at 30 min (3.1±0.912) in group L. Patients in group L requested early rescue analgesic at 30±8.633 min compared with 49.64±7.958 min in group LD. CONCLUSIONS: Diltiazem as an adjunct to lignocaine provided enhanced intraoperative and post-operative analgesia without any significant side effects.

Comparison of the performance of 'Intubating LMA' and 'Cobra PLA' as an aid to blind endotracheal tube insertion in patients scheduled for elective surgery under general anesthesia.

OBJECTIVE: Supraglottic airways (SGA) through which blind endotracheal intubation is made possible is an area of considerable interest. Our study aimed at comparing the Cobra Perilaryngeal Airway (CPLA) with the Intubating Laryngeal Mask Airway (ILMA) with regard to the performance of the former as a conduit for facilitating blind endotracheal intubation. METHODS: American Society of Anesthesiologists (ASA) I-II patients consenting to the study, with no predictors of difficult airway, scheduled for elective surgery were randomized into two groups of 30 each. Anesthesia was induced with fentanyl, propofol and vecuronium. CPLA was inserted in Group I and ILMA in Group II. Fibreoptic scoring of the laryngeal view was done through the SGA. Blind intubation through either CPLA or ILMA was then carried out with cuffed polyvinyl chloride (PVC) tube in Group I and ILMA-tracheal tube in Group II. RESULTS: Demographic and surgical data were comparable between the two groups. The success rate of intubation (87% through CPLA and 90% through ILMA) (p value 1), number of attempts made and the fibreoptic scores (p value 0.12) were comparable between the two groups. Insertion time was significantly longer in Group I as compared with Group II (9 s vs. 4 s; p value 0.004). Trauma and sore throat were more common in Group I (p value -0.1, 0.19 respectively). Hemodynamic monitoring showed more tachycardia during CPLA insertion as compared with ILMA (p value 0.006). CONCLUSION: We conclude that CPLA can be used as an effective conduit for blind endotracheal intubation with cuffed PVC tube and has comparable efficacy in tracheal intubation as that with ILMA.

Life threatening subcutaneous emphysema following surgical repair of tracheocutaneous fistula.

A 9-year-old male child posted for closure of tracheocutaneous fistula developed extensive subcutaneous emphysema resulting in acute respiratory distress immediately after transfer to recovery room. The clinical management, precautions and other complications of closure of tracheocutaneous fistula are discussed.