Comparison of ultrasound-guided transversalis fascia and posterior transversus abdominis plane block for postoperative analgesia following caesarean delivery: A double-blinded randomised controlled trial.

Background and Aims: Posterior-transversus abdominus plane (TAP) block and transversalis fascia plane (TFP) block have been used for postoperative analgesia following caesarean delivery. We compared the analgesic efficacy of the TAP vs TFP plane blocks in patients undergoing elective caesarean delivery. Methods: We randomised 90 women undergoing caesarean delivery under spinal anaesthesia to receive either a posterior-TAP (Group-TAP), TFP (Group-TFP) or no block (Group-C) postoperatively. The primary objective was the postoperative analgesic requirements. Secondary objectives were duration of analgesia, pain scores and infra-umbilical sensory loss, which were recorded at specific intervals for 24 h. Statistical analysis was carried out using Statistical Package for Social Sciences version 16.0 software. Results: The patients requiring one, two or nil rescue analgesics were comparable between the interventions and the control (P = 0.32). The duration of analgesia was longer in Group-TAP when compared to Group-C, 4.76 (1.2) vs. 6.89 (2.4); P < 0.001, whereas Group-TFP, 5.64 (2.1) h, was not significantly different from Group-C. The static pain score in Group-TAP was significantly less than that in Group-C at 4 h and beyond 12 h (P < 0.001), whereas Group-TFP was comparable with Group-C at all time points except at 4 h and 24 h (P = 0.002). Only Group-TAP demonstrated midline infraumbilical sensory loss. Conclusion: TAP and TFP blocks did not decrease the rescue analgesic requirement compared with the control group. The posterior-TAP block prolonged the duration of analgesia by 2 h, maintained the median static pain score at 0 beyond 12 h, and demonstrated sensory loss at the infraumbilical dermatomes.

Effectiveness of Face mask only oxygenation and apnoeic oxygenation in addition to face mask in sustaining PaO2 during rapid sequence induction - A randomized control trial.

Background and Aims: Apnoeic oxygenation, although useful during elective intubations, has not shown consistent beneficial results during emergency intubations in critically ill patients. We aimed to study the effectiveness of adding apnoeic oxygenation to our routine practice of using facemask alone, in emergency laparotomy patients needing rapid sequence induction (RSI), for sustaining partial pressure of oxygen (PaO2). Material and Methods: Seventy-two patients undergoing RSI for emergency laparotomy were randomly allocated to either receive pre-oxygenation with 5 L/min of oxygen (O2) with a facemask (Group-FM) or apnoeic oxygenation with 10 L/min of O2 through a nasal catheter in addition to pre-oxygenation (Group-NC). Apnoea (90 s) was allowed from the removal of the facemask before the resumption of ventilation. Arterial blood gas analysis was done at the baseline, following pre-oxygenation and after 90 s of apnoea to study the PaO2 and partial pressure of carbon dioxide (PaCO2). The circuit O2 concentrations (fraction of inspired [FiO2] and end-tidal [EtO2]) were also noted to ensure a steady state of O2 uptake was reached. Results: The circuit O2 concentrations were 90 ± 4% in group FM and 93 ± 5% in Group-NC. The FiO2-EtO2 difference was 4% in both groups. During the 90 s apnoea following pre-oxygenation, there was a fall in the PaO2 by 38% in Group-FM and 12% in Group-NC (P = 0.000). Increase in PaCO2 was similar in both groups (Group-FM: 44 [range: 32-55] mmHg; Group-NC: 42 [range: 33-54] mmHg, P = 0.809). Conclusion: Apnoeic insufflation of O2 using a nasopharyngeal catheter along with facemask oxygenation is more effective in sustaining PaO2 for 90 s during RSI than facemask-only oxygenation in patients undergoing emergency laparotomy.

Ultrasound measurement of the distance of the phrenic nerve from the brachial plexus at the classic interscalene point and upper trunk: A volunteer-based observational study.

Background and Aims: The method of blocking the brachial plexus at the level of the upper trunk has been gaining popularity as a phrenic nerve-sparing alternative for interscalene block. We aimed to measure the distance of the phrenic nerve from the upper trunk and compare it with the distance between the phrenic nerve and the brachial plexus at the classic interscalene point by using ultrasound. Method: In this study, after ethical approval and trial registration, 100 brachial plexus of 50 volunteers were scanned from the emergence of the ventral rami and its course was traced to the supraclavicular fossa. The distance of the phrenic nerve from the brachial plexus was measured at two levels: the interscalene groove along the cricoid cartilage (classic interscalene block point) and from the upper trunk. The presence of anatomical variations of the brachial plexus, the classic traffic light sign, vessels across the plexus, and the location of the cervical oesophagus were also noted. Results: At the classic interscalene point, the C5 ventral ramus was observed to be just emerging or to have fully emerged from the transverse process. The phrenic nerve was identified in 86/100 (86%) of scans. The median (IQR) distance of the phrenic nerve from the C5 ventral ramus was 1.6 (1.1-3.9) mm and that of the phrenic nerve from the upper trunk was 17 (12-20.5) mm. Anatomical variations of the brachial plexus, the classic traffic light sign, and vessels across the plexus were seen in 27/100, 53/100, and 41/100 scans respectively. The oesophagus was consistently located on the left side of the trachea. Conclusions: There was a 10-fold increase in the distance of the phrenic nerve from the upper trunk when compared to that from the brachial plexus at the classic interscalene point.

Technological advances in the production of carotenoids and their applications- A critical review.

Carotenoids are naturally occurring pigments that are widely distributed in algae, fungi, bacteria, and plants. Carotenoids play a significant role in the food, feed, cosmetic, nutraceutical, and pharmaceutical industries. These pigments are effectively considered as a health-promoting compounds, which are widely used in our daily diet to reduce the risk of chronic diseases such as cardiovascular diseases, cancer, acute lung injury, cataracts, neural disorders, etc. In this context, this review paper demonstrates the synthesis of carotenoids and their potential application in the food and pharmaceutical industries. However, the demand for carotenoid production is increasing overtime, and the extraction and production are expensive and technically challenging. The recent developments in carotenoid biosynthesis, and key challenges, bottlenecks, and future perspectives were also discussed to enhance the circular bioeconomy.

Baska Mask is non-inferior to tracheal tube in preventing airway contamination during controlled ventilation in elective nasal surgeries: A randomised controlled trial.

BACKGROUND AND AIMS: Baska Mask, a newly designed third-generation supraglottic device, has a sump where the pharyngeal secretions can collect and be suctioned out continuously. We aimed to study the effectiveness of Baska Mask in preventing airway contamination during nasal surgeries. Our primary objective was to assess airway soiling using fibreoptic bronchoscopy. Total airway manipulation time, haemodynamic parameters during device insertion and post-operative oro-pharyngeal morbidities were the secondary objectives. METHODS: Eighty-four participants undergoing nasal surgeries were randomised to either have their airway maintained with Baska Mask (Group-BM) or Endotracheal tube (Group-TT). Fibreoptic bronchoscopy was performed at the end of the surgery and the airway was inspected for signs of contamination. Total airway manipulation time, haemodynamic parameters during device insertion and post-operative oro-pharyngeal morbidities were also assessed. Unpaired Student's t test was used for parametric data and Chi-square test for nonparametric data. One-way analysis of variance (ANOVA) was used for the intra-group analysis of haemodynamic data. RESULTS: Tracheal contamination was not observed in any patient in either group. Time taken for device insertion (Group TT: 24.24 ± 6.86 s vs. Group BM: 24.22 ± 7.3 s; P = 0.97) was similar in both the groups. The total airway manipulation time was 2 min longer in Group-TT (P = 0.000) due to additional time taken for insertion of throat pack. Haemodynamic parameters during device insertion were stable and post-operative oro-pharyngeal morbidities were fewer with Baska Mask when compared to Tracheal tube. CONCLUSIONS: Baska Mask is non-inferior to tracheal tube in preventing tracheal contamination in patients undergoing nasal surgeries.

Comparison of recovery characteristics with two different washout techniques of desflurane anaesthesia: A randomised controlled trial.

BACKGROUND: Rapid emergence with low soluble inhalational agents (IA) is offset by a significant association with emergence agitation (EA). Research on the influence of elimination methods of IA on recovery characteristics is very few. We conducted this study to compare the recovery characteristics of slow elimination (SE) of desflurane with purging technique. METHODOLOGY: Forty-five participants, 18-60 years, undergoing elective laparoscopic surgeries were randomised either into Group-P (n = 23) or Group-SE (n = 22). A standardised induction-maintenance protocol including desflurane and fresh gas flow (FGF) of 0.8 l/min was followed. During recovery, the FGF was increased in Group-P to 10 L/min and in Group-SE it was continued at 0.8 L/min. The decrement in end-tidal concentration of desflurane, time for emergence and extubation, EA and time for psychomotor recovery were noted. RESULTS: Time for emergence (Group-SE: 22.8 ± 9 vs. Group-P: 5.6 ± 1.5 min; P = 0.000) and emergence to extubation duration (Group-SE: 128 ± 36 s vs. Group-P: 11.5 ± 1.7 s; P = 0.000) were longer in the Group-SE than in Group-P. EA occurred in 22.7% patients in Group-SE and in 4.3% patients in Group-P (P = 0.07). Psychomotor recovery to baseline values was seen in more number of patients in Group-SE than Group-P at 30 min. There was no difference between the groups at 60 min post-extubation. CONCLUSIONS: Slow elimination using FGF of 0.8 L/min significantly prolongs emergence even with low soluble agent like desflurane. SE is not beneficial in decreasing the incidence of EA or hastening psychomotor recovery. Purging technique is, therefore, a better-suited technique with fewer complications for eliminating desflurane.

Truncal injection brachial plexus block: A Description of a novel injection technique and dose finding study.

BACKGROUND AND AIMS: Brachial plexus (BP) blocks continue to be described with reference to anatomical landmarks (Interscalene and Supraclavicular), even after the introduction of ultrasound which enables us to directly identify the roots, trunks and divisions of the BP. The aim of this study was to describe a novel injection technique targeting trunks of BP and to determine the minimum effective local anaesthetic volume (MELAV) required to produce BP block with this approach. METHODS: Twenty-one male patients in the age group 20-40 years, undergoing elective forearm bony procedures received an ultrasound-guided truncal injection BP block. MELAV50 was determined using the Dixon and Mood up-and-down method. Initial volume of local anaesthetic (LA; 50:50 mixture of bupivacaine 0.5% and lignocaine 2% with 5 µg/ml epinephrine) injected was 6 ml in each trunk, which was varied by 1 ml/trunk for each consecutive patient according to the response of the previous patient. The MELAV50, MELAV95 and MELAV99 were calculated using Probit transformation and logistic regression. RESULTS: Out of the 21 patients, 13 patients had a successful block. The MELAV50, MELAV95 and MELAV99 were 7.41, 10.47 and 12 ml, respectively. Eight patients in whom block failed had sparing in the ulnar and median nerve territories. CONCLUSION: Trunks of the brachial plexus can be identified and targeted for the injection of local anaesthetics. The MELAV50 and MELAV95 required for ultrasound-guided truncal injection brachial plexus block were 7.4 and 10.4 ml, respectively.

Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway.

BACKGROUND AND AIMS: Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements. MATERIAL AND METHODS: One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted. RESULTS: Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26-80) s and 49 (range 28-83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups. CONCLUSION: Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt.

Denudation of human amniotic membrane by a novel process and its characterisations for biomedical applications.

This study was aimed to investigate the suitability of a modified method to get decellularised human amniotic membrane (DHAM). The obtained membrane was subjected to physico-chemical and biological evaluations to validate its potential for biomedical applications. The human amniotic membrane was processed with detergent and alkali followed by enzymatic treatments. Hematoxylin and eosin (H&E) and Masson's trichrome staining of membrane were in accordance with conjectures: the decellularised membrane stained for extracellular matrix is rich in collagen. Scanning electron micrograph also showed the denudation in the processed membrane with the cellular impressions on the basement membrane. Physical characteristics namely the differential scanning calorimetric, tensile, shrinkage behaviour and the Fourier transform infrared spectra of decellularised membrane showed its stability and intact structure similar to the unprocessed membrane. In the visible range of light, the membrane was found to be transparent from 90 to 98 %. Proliferation rate of fibroblasts, keratinocytes, myoblasts and hepatocytes were significantly upregulated compared to the control. The cell morphologies were normal and differentiation of myoblasts into myotubes were more pronounced in decellularised membrane. Proliferation of corneal limbal cells on decellularised membrane showed 92-100 % confluency on day 21 and the migrated cells displayed a spindle shape and changing later to a more cuboidal appearance.

Anesthetic management of intestinal obstruction: A postgraduate educational review.

Intestinal obstruction is associated with significant morbidity and mortality. Scientific assessment of the cause, site of obstruction, appropriate correction of the fluid deficit and electrolyte imbalance with preoperative stabilization of blood gases is ideal as a preoperative workup. Placement of a preoperative epidural catheter especially in the thoracic interspace takes care of perioperative pain and stress reduction. Intraoperative management by controlled general anesthesia administering a relative high inspired fraction of oxygen with invasive monitoring in selected sick cases is mandatory. Preoperative monitoring and stabilizing raised intra-abdominal pressure reduces morbidity. Caution should be exercised during opening and closure of abdomen to avoid cardiorespiratory ill effects. There should be an emphasis on avoiding hypothermia. The use of nonsteroidal anti-inflammatory drugs may worsen sick, fragile patients. The use of sugammadex rather than neostigmine will obscure certain controversies in the healing of intestinal anastomotic site. Replacement of blood loss continued correction of fluids and electrolytes with possible postoperative mechanical ventilation in sick cases may improve outcomes in these patients.

Rapid and reliable smooth extubation - Comparison of fentanyl with dexmedetomidine: A randomized, double-blind clinical trial.

BACKGROUND: Fentanyl and dexmedetomidine have been tried to attenuate airway and circulatory reflexes during emergence and extubation individually but have not been compared with respect to the level of sedation to evolve a reliable technique for rapid and smooth extubation. AIM: To compare the effects of fentanyl and dexmedetomidine in attenuating airway and circulatory reflexes during emergence and extubation of the endotracheal tube. SETTING AND DESIGN: This double-blind, randomized, controlled study was done in patients undergoing surgery under general anesthesia belonging to the American Society of Anesthesiologists physical status 1 or 2. METHODOLOGY: All patients received a standardized anesthetic protocol. Patients were randomized to receive either fentanyl 1 µg/kg or dexmedetomidine 0.75 µg/kg. Fifteen minutes before expected last surgical suture, isoflurane was cutoff and equal amount of test solution was given when train-of-four ratio was 0.3. The degree of sedation, airway, and circulatory responses at the time of suction and extubation were analyzed. STATISTICAL ANALYSIS USED: Chi-square test for nonparametric data and t-test for parametric data. RESULTS: Heart rate (HR) was comparable in both the groups until endotracheal extubation. Later, there was rise in HR in fentanyl group. There was stastisticaly significant drop in blood pressure at 5 min after test drug administration in both the groups. Airway response for suctioning and extubation was better in dexmedetomidine group and it was associated with better sedation score than fentanyl group. CONCLUSION: Single dose of 0.75 µg/kg dexmedetomidine given 15 min before extubation provides smooth extubation when compared to fentanyl.

Assessment of suitability of i-gel and laryngeal mask airway-supreme for controlled ventilation in anesthetized paralyzed patients: A prospective randomized trial.

CONTEXT: Laryngeal mask airway supreme (LMA-S) has an inflatable cuff while i-gel has a noninflatable cuff made of thermoplastic elastomer. AIMS: To study the efficacy of ventilation and the laryngeal seal pressures (LSPs) with either device. Our secondary objectives were to compare the ease of insertion, adequacy of positioning the device, hemodynamic response to device insertion, and any postoperative oropharyngeal morbidity. SETTINGS AND DESIGN: A prospective, randomized, single-blinded study at Teaching Medical School in South India. MATERIALS AND METHODS: Forty-two patients posted for surgery under general anesthesia were randomly divided into two groups - LMA-S and i-gel. After a standardized premedication and anesthesia induction sequence, the supra-glottic devices were introduced. Ease of insertion was assessed from the number of attempts taken to insert, insertion time, and any maneuvers required to insert the device. Position of the device was assessed by the ease of gastric catheter placement and the fibreoptic grading of laryngeal visualization. Efficacy of ventilation was determined from the LSP, peak inspiratory pressure (PIP), and end-tidal carbon dioxide (EtCO2)values. Any postoperative oropharyngeal morbidity was also recorded. STATISTICAL ANALYSIS: Descriptive analysis was reported as a mean and standard deviation, median, and range of continuous variables. Demographics were analyzed using a unpaired t-test for parametric data and Chi-square test for nonparametric data. Respiratory and hemodynamic data was analyzed using one-way ANOVA to find statistical difference within and between the two groups. RESULTS: LMA-S was successfully inserted in 95% of patients and i-gel in 85.5% of patients. There was a significant difference (P = 0.021) in the LSPs between the two groups (18.15 cmH2O in LMA-S and 21.28 cmH2O in the i-gel group). There was no significant difference in the PIPs, leak fraction, and the EtCO2values. CONCLUSION: Both devices are suitable for positive pressure ventilation (PPV) in anesthetized paralyzed patients. However, i-gel gives a better laryngeal seal when compared to LMA-S and may be chosen preferentially for PPV.

Fixation of bilateral condylar fractures with maxillary and mandibular nerve blocks.

Mandibulo facial injuries present special problems to the anesthesiologist in terms of the difficult airway. Hence, if regional anesthesia could be possible, it necessarily removes the major concern with airway access. We present a case of bilateral mandibular condylar fracture dislocation with the maxillary and mandibular nerve blocks on both sides. The surgery went on smoothly without any perioperative problems.