Ultrasound-Guided Continuous Transmuscular Quadratus Lumborum Block for Postoperative Analgesia in Patients Undergoing Radical Nephrectomy: A Randomized Controlled Trial.

Introduction Ultrasound (US) guided transmuscular quadratus lumborum block (TMQLB) has been widely used as regional anaesthesia (RA) technique for managing postoperative pain after intraperitoneal and retroperitoneal procedures like nephrectomy, percutaneous nephrostomy, cholecystectomy, and also for hip surgeries. Although continuous epidural analgesia is considered the gold standard for most of these procedures, alternative techniques such as transversus abdominis plane (TAP) block and continuous rectus sheath block have also been used successfully. US-guided TMQLB seems to have more advantages than TAP block as it blocks the visceral afferents. With more cephalad spread of the local anaesthetic into the thoracic paravertebral space, it might block somatic pain from T6 to L2 as well. Methods After institutional ethics committee approval, we recruited 64 consecutive patients in the study and randomized them into two groups. Patients in the study group received bupivacaine (0.125%) and the control group received normal saline as a continuous infusion for 48 hours. Both groups were compared for 48 hours morphine consumption, time to first analgesic, hemodynamics, postoperative nausea/vomiting (PONV), sedation, and other adverse events. Results Data from 60 patients were analyzed. Forty-eight hours of morphine consumption in group A (study) was less than group B (7.4 ± 4.57 mg versus 11.86 ± 5.58 mg) and the time to first morphine requirement was 240 min (105-500) in group A compared to 90 min (90-225) in group B which was statistically significant. Demographic data, American Society of Anesthesiologists physical status, hemodynamics, Ramsay sedation score (RSS), and PONV were comparable in both groups. Conclusion Continuous US-guided TMQLB appears to be a safe and effective RA technique for managing postoperative pain after nephrectomy for up to 48 hours. Trial registration: German Clinical Trials Register-DRKS-ID: DRKS00014611.

An Observational Study for Knowing the Compliance of Patients Scheduled for Major Abdominal and Thoracic Cancer Surgeries in a Single Specialty Center.

BACKGROUND: Peri-operative incentive spirometry (IS) helps in improving pulmonary function, facilitates sputum clearance and prevents unwanted postoperative pulmonary complications after major abdominal and thoracic surgery. In our hospital, all patients are instructed to practice IS before abdominal and thoracic surgeries so that they can perform it in the postoperative period effectively. However, many patients do not follow our advice. A few unfortunate patients land up with pulmonary complications as it becomes difficult to train them after surgery. AIMS: To determine the compliance rate of patients who were instructed to perform incentive spirometry preoperatively. STUDY DESIGN AND SETTINGS: Observational, single arm study in a single speciality centre. MATERIALS AND METHODS: After approval from hospital ethics committee the study was registered with Clinical Trials Registry of India (CTRI). 100 patients posted for major abdominal or thoracic cancer surgery were enrolled in the study. They were instructed to perform incentive spirometry(IS) in front of relatives, an information leaflet was provided to them and the spirometry effort was noted in 'ml'. The effort was crossed checked on the day of surgery. Patients performing IS correctly with effort more or equal to that noted earlier were labelled as compliant. Others were labelled as non-compliant. The reason of non-compliance was to be determined using a questionnaire meant for patient and the accompanying family member. RESULTS: Out of 100, 26 patients were found to be non-compliant out of which 10 were males and 16 were female patients. 15 patients did not understand the instructions properly, 8 patients did not get enough time to practice, family members of 10 patients could not help the patient in performing and understanding IS, family members of 8 patients did not have adequate time for the patient. CONCLUSION: A non-compliance rate of 26% could be because patients and family members did not understand the seriousness of preoperative IS in spite of explaining and giving an information leaflet. The surgeries planned were major ones which require arrangement of finances, abstinence from work and other social issues like not having anybody at home with other family members, location of hospital far from the place they live. Involving respiratory therapist and nursing staff early during pre-anaesthesia check up could help in better understanding of the patient and family regarding benefits of IS.

Efficacy of bilateral greater occipital nerve block in postdural puncture headache: a narrative review.

The Epidural blood patch is considered the gold standard for managing postdural puncture headache when supportive measures fail. However, it is a procedure which can lead to another inadvertent dural puncture. Other potential adverse events that could occur during a blood patch are meningitis, neurological deficits, and unconsciousness. The bilateral greater occipital nerve block has been used for treating chronic headaches in patients with PDPH with a single injection. This minimally invasive, simple procedure can be considered for patients early, along with other supportive treatment, and an epidural blood patch can be avoided.