Use of intrathecal midazolam or fentanyl as an adjunct to spinal anaesthesia with bupivacaine for lower limb surgery: A randomised controlled study.

BACKGROUND: Intrathecal adjuncts have been used to prolong the quality and duration of subarachnoid anaesthesia. Midazolam given intrathecally is reported to have antinociceptive properties. The purpose of this study was to compare intrathecal midazolam with fentanyl for pain relief and patient comfort. METHODS: In this prospective, double-blind, randomised controlled trial, 90 patients for lower limb surgeries were randomly allocated to three groups: "control group" (3 ml 0.5% heavy bupivacaine), "fentanyl group" (3 ml 0.5% bupivacaine + 10 mcg fentanyl) and "midazolam group" (3 ml 0.5% bupivacaine + 1 mg midazolam). Level, duration, and quality of blocks were compared along with the duration and quality of postoperative analgesia. Haemodynamic stability and any associated complications were also noted. RESULTS: Onset of block was fastest in Group C (28.5 ± 13.48 min) vis-a-vis other groups (35.5 ± 26.05 min for Group "F" and 28.5 ± 23.68 min for Group "M"; P = 0.51). Duration of block was comparable in all groups (130.5 ± 39.3 min Group "C"; 126.5 ± 44.0 min Group "F" and 129.5 ± 45.7 min Group "M"; P > 0.5).Addition of adjuncts did not significantly defer the appearance of pain. Intensity of pain was lower in Group "M". Average VAS scores were lower for Group "M" (3-4) than those for Group "C" (4-5) and Group "F" (4-6).Majority of patients required at least one dose of rescue analgesic; however, those receiving fentanyl reported better quality of postoperative analgesia than those in midazolam group. CONCLUSION: Adjuvants improve quality of postoperative analgesia (fentanyl better than midazolam).

Bullet and Blast ENT Injuries in Counter-Insurgency Area.

BACKGROUND: Many ENT injuries are not recognized easily, but they have the potential of increasing the morbidity. METHODS: ENT injuries managed in two tertiary care Level-IV hospitals between 2006 and 2007 were studied with a view to formulate strategy in efficient management of these cases. RESULT: Emergency bags did not carry readymade packs to control nasal bleeds. Routinely screening of ears in all blast injury cases in the 'Blast Injury Program' helped in early identification of hearing loss. Lack of sufficient stenting of nasal cavities resulted in severe nasal stenosis which was difficult to repair. Splinters lodged in pharyngeal wall escaped detection, resulting in concealed haemorrhage and shock. CONCLUSION: Nasal packs and epistaxis catheters must be included in emergency bags to minimize blood loss at first contact. Screening for ear trauma in all blast injuries increases detection rate and is beneficial to the soldier. Stenting of injured nasal cavities and early transfer to a tertiary care hospital could reduce morbidity. Plain radiography of head and neck areas could help detect splinters in vital areas and guide management.