Evaluation of analgesic effects and hemodynamic responses of epidural ropivacaine in laparoscopic abdominal surgeries: Randomised controlled trial.

Background and Aims: The role of epidural analgesia in laparoscopic surgeries remains controversial. We evaluated intraoperative analgesic effects of epidural ropivacaine versus intravenous fentanyl in laparoscopic abdominal surgery and assessed postoperative analgesic requirements, hemodynamic changes, time to ambulation, and length of stay (LOS) in the ICU. Material and Methods: Seventy-two American Society of Anesthesiologists physical status I-III adult patients undergoing elective laparoscopic abdominal surgeries were randomized to either 0.5 mg/kg/h intravenous fentanyl (Group C) or 0.2% epidural ropivacaine at 5-8 mL/h (Group E) infusions intraoperatively and 0.25 m/kg/h fentanyl and 0.1% epidural ropivacaine infusions respectively postoperatively. Variations in mean arterial pressure (MAP) of 20% from baseline were points of intervention for propofol and analgesia with fentanyl or vasopressors. The number of interventions and total doses of fentanyl and vasopressors were noted. Postoperative analgesia was assessed at 0, 6, 12, and 24 h and when pain was reported with numerical rating scale and objective pain scores. Chi-square test and Student's t-test were used for categorical and continuous variable analysis. Results: Intraoperatively, 14 patients versus 4 needed additional fentanyl and 26 versus 14 needed additional propofol in groups C and E respectively (P = 0.007, P = 0.004). MAP at 0, 6 and 18 h was lower in Group E. Pain scores were better in Group E at 6,18, and 24 h postoperatively. Time to ambulation was comparable but LOS ICU was prolonged in Group E (P = 0.05). Conclusion: Epidural ropivacaine produces superior intraoperative analgesia and improved postoperative pain scores without affecting ambulation but increases vasopressor need and LOS ICU in comparison with intravenous fentanyl in laparoscopic abdominal surgeries.

Comparison of Hemodynamic Changes to Nasal Application of Lignocaine Jelly versus Lubricant Gel and Responses to Ryle's Tube Insertion Following Their Use in Patients Under General Anesthesia.

BACKGROUND: Awake patients complain of burning sensation following nasal application of lignocaine jelly. AIM OF THE STUDY: The aim of the study was to assess hemodynamic changes, ease of insertion, number of attempts taken, and time required for insertion of Ryle's tube following nasal application of 2% lignocaine jelly versus lubricant gel in patients undergoing surgeries under general anesthesia. SETTINGS AND DESIGN: This was a prospective, randomized, open-label study conducted in a tertiary care institute. SUBJECTS AND METHODS: Eighty patients undergoing surgeries under general anesthesia who required insertion of a Ryle's tube were included. In Group A, 2% lignocaine jelly was used, whereas in Group B, lubricant gel was used prior to Ryle's tube insertion, after induction of anesthesia. Hypertension and/or tachycardia were managed by increasing sevoflurane by 0.5%-1%, followed by propofol bolus of 0.5 mg.kg-1. STATISTICAL TESTS USED: Chi-square test and Independent samples t test. RESULTS: Both heart rate and mean arterial pressure were significantly higher at 1 min after nasal application of lignocaine jelly and 1 and 5 min after Ryle's tube insertion in Group A compared to Group B. Ease of insertion of Ryle's tube, number of attempts, and time taken for insertion were comparable in both groups. Significantly higher number of patients in Group A required sevoflurane to be increased and needed propofol boluses. CONCLUSION: Use of lubricant gel for aiding insertion of Ryle's tube in patients under general anesthesia was associated with attenuated heart rate and blood pressure responses without affecting the ease, number of attempts, or time taken for successful insertion of the Ryle's tube.

May Measurement Month 2017: an analysis of blood pressure screening results from the United Arab Emirates-Northern Africa and Middle East.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programmes worldwide. United Arab Emirates has a young population, but cardiovascular disease (CVD) is the commonest cause of death (40%). Myocardial infarction and stroke occurs at least a decade earlier than in western countries. Previous screening in our young population showed that 85% of the population had at least one CVD risk factor and about 62% of them were unaware of it. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. Screening was held in 23 sites such as mosques, sports, and men's/ladies' clubs, airports, parks, shopping malls, work places as well as their residences, and in the public areas of hospitals or outpatient clinics. A total of 6193 individuals were screened during MMM17. The mean age was 39.2 ± 13.1 years. After multiple imputation, 1867 (30.2%) had hypertension. Of individuals not receiving anti-hypertensive medication, 813 (15.8%) were hypertensive. Of 1054 individuals receiving anti-hypertensive medication, 427 (40.6%) had uncontrolled BP. MMM17 was a useful screening model as it makes BP measurement easily accessible. Eight hundred and thirteen (16%) possibly new hypertensives were uncovered and 427(40.6%) of those on treatment for hypertension were found to be uncontrolled. These results suggest that opportunistic screening can identify significant numbers with raised BP.

Coresidence with mother-in-law and maternal anemia in rural India.

In a highly patriarchal society such as India, and many Middle Eastern, African, and East Asian countries, coresidence with the mother-in-law is ubiquitous during the early years of marriage. During the period when women have to make crucial fertility decisions, they are under the supervision of the mother-in-law. Using the National Family Health Survey 2005-2006, and estimation strategies such as propensity score (PS) weighted regressions and a difference-in-differences type approach with PS matching, we estimate the causal effect of coresidence during pregnancy on maternal anemia among rural women in India. Here, coresidence and non-coresidence during pregnancy define our treatment and control, respectively. Women coresiding with both in-laws had fewer children, were younger, more educated, wealthier, and less likely to be Muslim and from scheduled castes and tribes compared to non-coresident women. Results indicate that the mother-in-law is a potentially valuable resource during pregnancy. For example, living with the mother-in-law reduced the likelihood of moderate to severe anemia by 13.2 percentage points compared to no coresidence. Under joint coresidence with both in-laws, the effect dropped to 8.5 percentage points. Moreover, women living with the mother in-law were 16.8 percentage points more likely to receive any iron supplementation. From a public health perspective and for policy making, the results indicate that safe motherhood programs should be augmented with awareness generation components which target the mother-in-law. Furthermore, pregnant women in nuclear families need particular attention.

Efficiency and Efficacy of Two Techniques of Preoxygenation during Modified Rapid Sequence Intubation.

BACKGROUND: Apneic mass movement of oxygen by applying continuous positive airway pressure (CPAP) is possible only when the airway is kept patent which helps to reduce the rate of desaturation. AIMS: The aim of this study was to check the efficiency of preoxygenation and apneic oxygenation by assessing the drop in partial pressure of arterial oxygen (PaO2) during apnea with and without keeping an oropharyngeal airway to maintain the patency of airway. SETTINGS AND DESIGN: This prospective observational study was conducted at a tertiary care center. MATERIALS AND METHODS: Sixty patients undergoing robotic and laparoscopic-assisted surgeries requiring modified rapid sequence intubation were recruited for the study. In Group A, CPAP was not applied during preoxygenation and oropharyngeal airway was not used, but oxygen was administered at 5 L/min during the apnea. In Group B, CPAP of 5 cmH2O was maintained during preoxygenation and after induction an oropharyngeal airway was inserted. Patients in both the groups were induced and paralyzed following standardized anesthesia protocol. STATISTICAL ANALYSIS USED: Chi-square test, independent t-test, and ANCOVA were used as applicable. RESULTS: Group B showed significantly higher mean PaO2 levels after preoxygenation (525.3 ± 42.5 vs. 500.8 ± 51) and at 90 s of apnea (494.8 ± 42.6 vs. 368.6 ± 98.4) as compared to Group A. The fall in PaO2 was significantly lower in Group B. The rise in partial pressure of arterial carbon dioxide was comparable in both groups. CONCLUSION: Preoxygenation with CPAP of 5 cmH2O followed by apneic oxygenation with CPAP keeping the airway patent with an oropharyngeal airway results in significantly higher PaO2 after preoxygenation and slower reduction in PaO2 during apnea.

Extracorporeal membrane oxygenation for post-transplant hypoxaemia following very severe hepatopulmonary syndrome.

Hepatopulmonary syndrome (HPS) associated with end-stage liver disease has a high morbidity when room air PaO2 is less than 50 mm Hg. Safe levels of oxygenation to facilitate transplantation have not been defined despite advancement in care. Postoperatively, hypoxaemia worsens due to ventilation perfusion mismatch contributed by postoperative pulmonary vasoconstriction and due to decrease in endogenous nitric oxide. A 16-year-old boy with cirrhosis presented with HPS and a PaO2 of 37 mm Hg on room air and underwent living donor liver transplant. Although stable intraoperatively, he desaturated on the second postoperative day. Despite a number of interventions, oxygenation remained critically low on 100% inspired oxygen. Extracorporeal membrane oxygenator (ECMO) was established with instant improvement in oxygenation (PaO268 mm Hg), and the patient was eventually salvaged. We suggest that ECMO could be a means of managing refractory post-transplant hypoxaemia in patients with HPS.

Comparison of Usefulness of Ketamine and Magnesium Sulfate Nebulizations for Attenuating Postoperative Sore Throat, Hoarseness of Voice, and Cough.

CONTEXT: Postoperative sore throat (POST) is a complication that is unresolved in patients undergoing endotracheal intubation. AIM: To compare the effects of ketamine and magnesium sulfate nebulizations in two strengths, on the incidence and severity of POST, hoarseness, and cough. SETTINGS AND DESIGN: Sixty surgical patients undergoing elective abdominal and lower limb surgeries under combined epidural and general anesthesia were included in this prospective, randomized, double-blinded study. SUBJECTS AND METHODS: Patients in each group were nebulized with the respective study drug 15 min prior to the surgery, i.e., ketamine in Group K, magnesium sulfate 250 mg, and 500 mg in Group M1 and Group M2, respectively, and normal saline as control in Group C. A standardized anesthesia protocol was followed for all patients. After extubation, the patients were asked to grade POST, hoarseness, and cough at 0, 2, 4, 12, and 24 h. STATISTICAL ANALYSIS USED: One-way analysis of variance, Chi-square test, Fisher's exact test, paired t-tests, and Wilcoxon's signed-rank test as applicable. RESULTS: Ketamine and magnesium sulfate 500 mg demonstrated a statistically significant decrease in POST at 0, 2, and 4 h, and postoperative hoarseness at 0 h. There was decrease in the incidence and severity of sore throat, hoarseness, and cough at all periods in the study groups as compared with control. CONCLUSION: Nebulization with ketamine 50 mg and magnesium sulfate 500 mg, 15 min before induction of general anesthesia and intubation, reduce the incidence and severity of POST and hoarseness of voice.

Metabolic profile in right lobe living donor hepatectomy: Comparison of lactated Ringer's solution and normal saline versus acetate based balanced salt solution - a pilot study.

BACKGROUND AND AIMS: Lactate levels predict outcomes after hepatectomy. We compared metabolic effects of lactated versus lactate free solutions in living donor hepatectomy. METHODS: Consecutive right lobe donors (n = 53) were alternatively allotted to lactated Ringer's solution and normal saline (Group L-control) or acetated crystalloid (Sterofundin B Braun® Group S -study group) in an observational prospective randomised study. The primary outcome measure was lactate level, and secondary outcomes were base excess, bicarbonate, glucose and chloride intra- and post-operatively. Mann-Whitney and Chi-square tests were used for analysis. RESULTS: The intraoperative, post-operative lactate levels and the time for normalisation were comparable. Group L had significantly lower intraoperative bicarbonate levels (mmol/L) at 6 and 8 h (20.0 ± 2.14 vs. 21.3 ± 1.6, P = 0.0471; 18.68 ± 2.04 vs. 20.39 ± 17, P = 0.002), base excess at 4 and 6 h (mmol/L) (-3.64 ± 2.73 vs. -3.0 ± 1.52, P = 0.031; -6.64 ± 2.76 vs. -4.35 ± 1.7 P = 0.006). The intraoperative chloride levels (mmol/L) were higher in group L at 4 and 8 h (108 ± 5.9 vs. 105.99 ± 2.76, P = 0.0471; 109.51 ± 3.86 vs. 106.93 ± 3.09, P = 0.002). Intraoperative glucose (mg/dL) at 6 h was higher in group L, 160.55 ± 31.52 vs. 145.5 ± 24.29, P = 0.043. The highest post-operative chloride (mmol/L) was higher in Group L (112.3 ± 3.86 vs. 109.81 ± 3.72, P = 0.034). Post-operative base excess and bicarbonate showed an improved profile in Group S (-7.37 ± 2.99 vs. -5.06 ± 1.71 P = 0.001 and 17.79 ± 2.23 vs. 19.68 ± 1.51 P = 0.005). CONCLUSION: Acetated fluids were associated with higher levels of bicarbonate, lesser base deficit, glucose and chloride but no difference in lactate levels in comparison with Ringer's lactate and normal saline in living donor hepatectomy.

Lipoma of the submandibular space.

Lipomas in the submandibular space are uncommon. This report describes a case of lipoma in the submandibular space. The clinical features, imaging study, histopathological features and management of the tumor are described.